LTD Cases Involving Reflex Sympathetic Dystrophy Syndrome / Complex Regional Pain Syndrome

Long Term Disability Cases Involving Reflex Sympathetic Dystrophy Syndrome/Complex Regional Pain Syndrome

This page explains how claims representatives develop and evaluate claims for long term disability insurance benefits on the basis of Reflex Sympathetic Dystrophy Syndrome (RSDS), also frequently known as Complex Regional Pain Syndrome, Type I (CRPS). These terms are synonymous and are used to describe a unique clinical syndrome that may develop following trauma. This syndrome is characterized by complaints of intense pain and typically includes signs of autonomic dysfunction.

Background

RSDS/CRPS are terms used to describe a constellation of symptoms and signs that may occur following an injury to bone or soft tissue. The precipitating injury may be so minor that the individual does not even recall sustaining an injury. Other potential precipitants suggested by the medical literature include, but are not limited to, surgical procedures, drug exposure, stroke with hemiplegia, and cervical spondylosis.

What Is RSDS/CRPS?

RSDS/CRPS is a chronic pain syndrome most often resulting from trauma to a single extremity. It can also result from diseases, surgery, or injury affecting other parts of the body. Even a minor injury can trigger RSDS/CRPS. The most common acute clinical manifestations include complaints of intense pain and findings indicative 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 degree of pain reported is out of proportion to the severity of the injury sustained by the individual. When left untreated, the signs and symptoms of the disorder may worsen over time.

Although the pathogenesis of this disorder (the precipitating mechanism(s) of the signs and symptoms characteristic of RSDS/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 respond to a stressful stimulus by “fight or flight.” The so-called “fight or flight” response is characterized by constriction of peripheral vasculature (blood vessels supplying skin), increase in heart rate and sweating, dilatation of bronchial tubes, dilatation of pupils, increase in level of alertness, and constriction of sphincter musculature.

Abnormal sympathetic nervous system function may produce inappropriate or exaggerated neural signals that may be misinterpreted as pain. In addition, abnormal sympathetic stimulation may produce changes in blood vessels, skin, musculature and bone. Early recognition of the syndrome and prompt treatment, ideally within 3 months of the first symptoms, provides the greatest opportunity for effective recovery.

How Does RSDS/CRPS Typically Present?

RSDS/CRPS patients typically report persistent, burning, aching or searing pain that is initially localized to the site of the injury. The involved area usually has increased sensitivity to touch. The degree of reported pain is often out of proportion 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 to remote parts of the body.

Clinical studies have demonstrated that when treatment is delayed, the signs and symptoms may progress and spread, resulting in long-term and even permanent physical and psychological problems. Some investigators have found that the signs and symptoms of RSDS/CRPS persist longer than 6 months in 50 percent of cases, and may last for years in cases where treatment is not successful.

What Are the Diagnostic Criteria for RSDS/CRPS?

A diagnosis of RSDS/CRPS requires the presence of complaints of persistent, intense pain that results in impaired mobility of the affected region. The complaints of pain are associated with:

  • Swelling;
  • Autonomic instability—seen as changes in skin color or texture, changes in sweating (decreased or excessive sweating), skin temperature changes, or abnormal pilomotor erection (gooseflesh);
  • Abnormal hair or nail growth (growth can be either too slow or too fast);
  • Osteoporosis; or
  • Involuntary movements of the affected region of the initial injury.

Progression of the clinical disorder is marked 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. Efficacy of treatment must be judged on the basis of the treatment’s effect on the pain and whether or not progressive changes continue in the tissues of the affected region.

Reported pain at the site of the injury may be followed by complaints of muscle pain, joint stiffness, restricted mobility, or abnormal hair and nail growth in the affected region. Further, signs of autonomic instability (changes in the color or temperature of the skin and frequent appearance of goose bumps) may develop in the affected region. Osteoporosis may be noted by appropriate medically acceptable imaging techniques. Complaints of pain can further intensify, and can be reported to spread to involve other extremities. Muscle atrophy and contractures can also develop. Persistent clinical progression resulting in muscle atrophy and contractures, or progression of complaints of pain to include other extremities or regions, in spite of appropriate diagnosis and treatment, hallmark a poor prognosis.

How Is RSDS/CRPS Treated?

Patient education and activity programs designed to increase limb mobility and promote use of the extremity or affected region during activities of daily living are considered the most important treatments for RSDS/CRPS. The medical literature has demonstrated that individuals affected by RSDS/CRPS have a better prognosis when they receive an early diagnosis and mobility is immediately encouraged. 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 mental evaluation may be requested by treating or other medical sources to determine if any undiagnosed psychiatric disease is present that could potentially contribute to a reduced pain tolerance. It is important to recognize that such evaluations are not based on concern that RSDS/CRPS findings are imaginary or etiologically linked to psychiatric disease. The behavioral and cognitive effects of the medications used to treat pain need to be thoroughly considered in the evaluation of this syndrome.

Other types of medications may also be used to reduce pain. Anti- inflammatory preparations, psychotropic medications (for example, antidepressants), certain antiepileptic drugs, muscle relaxants, and drugs that produce generalized reduction in sympathetic outflow may be tried in an effort to reduce the signs and symptoms associated with RSDS/CRPS and improve the mobility of the affected region.

Patients who are noted to have a good response to local sympathetic blocks may be considered candidates for surgical sympathectomy. This procedure permanently disrupts the sympathetic innervation of the affected region. It involves destroying a sympathetic ganglion and must be performed by a physician who is an expert in this technique. This procedure is not without risk of post-surgical complications.

How Is RSDS/CRPS Evaluated in a Long Term Disability Insurance Claim?

Disability is not typically established on the basis of an individual’s statement of symptoms alone. RSDS/CRPS may constitute the basis for a long term disability (LTD) insurance claim when it is documented by appropriate medical signs, symptoms, and laboratory findings, as discussed above.

For purposes of an LTD claim evaluation, RSDS/CRPS is established in the presence of persistent complaints of pain that are typically out of proportion to the severity of any documented precipitant and one or more of the following clinically documented signs in the affected region at any time following the documented precipitant:

  • Swelling;
  • Autonomic instability—seen as changes in skin color or texture, changes in sweating (decreased or excessive sweating), changes in skin temperature, and abnormal pilomotor erection (gooseflesh);
  • Abnormal hair or nail growth (growth can be either too slow or too fast);
  • Osteoporosis; or
  • Involuntary movements of the affected region of the initial injury.

When longitudinal treatment records document persistent limiting pain in an area where one or more of these abnormal signs has been documented at some point in time since the date of the precipitating injury, disability claims handlers can reliably determine that RSDS/CRPS is present and constitutes a disability eligible for benefits. It may be noted in the treatment records that these signs are not present continuously, or the signs may be present at one examination and not appear at another. Transient findings are characteristic of RSDS/CRPS.

How Is Medical Evidence of the Impairment Documented?

In cases involving RSDS/CRPS, the documentation of medical signs or laboratory findings at some point in time in the clinical record since the date of the precipitating injury is critical in establishing the presence of a medical condition that qualifies for long term disability benefits. In cases in which RSDS/CRPS is alleged, longitudinal clinical records reflecting ongoing medical evaluation and treatment from the individual’s medical sources, especially 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 unusual in cases of RSDS due to the transitory nature of its objective findings and the complicated diagnostic process involved.

Medical opinions from treating sources about the nature and severity of an individual’s impairment(s) are important in an LTD claim due to RSDS. 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 RSDS/CRPS Established?

The signs and symptoms of RSDS/CRPS may remain stable over time, improve, or worsen. Documentation should, whenever appropriate, include a longitudinal clinical record containing 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 sustain work activity over time.

Chronic pain and many of the medications prescribed to treat it may affect an individual’s ability to maintain attention and concentration, as well as adversely affect his or her cognition, mood, and behavior, and may even reduce motor reaction times. These factors can interfere with an individual’s ability to sustain work activity over time, or preclude sustained work activity altogether. When evaluating duration and severity, as well as when evaluating RFC, the effects of chronic pain and the use of pain medications should be carefully considered.

How Is RSDS/CRPS Evaluated in a Long Term Disability Claim?

Given that a variety of symptoms can be associated with RSDS/CRPS, the insurance claims adjudicator 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 do 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 substantiated by objective medical evidence, the adjudicator should make a finding on the credibility of the individual’s statements based on a consideration 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 other persons 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 finding, an individual’s symptoms and the effect(s) of those symptoms on the individual’s ability to function must be considered both in determining impairment severity and in assessing the individual’s residual functional capacity (RFC), as appropriate. In other words, the adjudicator should evaluate whether pain or other symptoms cause a limitation or restriction having more than a minimal effect on an 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 effects of pain and its treatment on an individual’s capacity to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis.

Opinions from an individual’s medical sources, especially treating sources, concerning the effect(s) of RSDS/CRPS on the individual’s ability to function in a sustained manner in performing work activities, or in performing activities of daily living, are important in enabling LTD insurance adjudicators to draw conclusions about the severity of the impairment(s) and the individual’s RFC. In this regard, any information a medical source is able to provide contrasting the individual’s medical condition(s) and functional capacities since the alleged onset of RSDS/CRPS with the individual’s status prior to the onset of RSDS/ CRPS is helpful to the adjudicator in evaluating the individual’s impairment(s) and the resulting functional consequences.

The conclusion about whether individuals are disabled will depend primarily on the nature and extent of their functional limitations or restrictions.

Long Term Disability Attorney for RSDS

The Ortiz Law Firm has experience in handling long term disability claims due to RSD. If your Long Term Disability claim for RSDS has been denied or terminated, call Mr. Ortiz for a free case evaluation at 850-308-7833.