What Is...Complex Regional Pain Syndrome?

June 14, 2010

Author: Catherine M. Callery (Kate)| Louise M. Tarantino

Complex Regional Pain Syndrome (CRPS), previously known as Reflex Sympathetic Dystrophy (RSD) is characterized by intense burning or aching pain or autonomic dysfunction, which worsens over time. RSD/CRPS most often results from an illness or trauma to a single extremity that did not directly damage the bones, joints, tissue or nerves in the affected limb. It is referred to as Causalgia when following a distinct nerve injury after forceful trauma to an arm or leg in the case of a gunshot wound or shrapnel blast. Other major/minor traumas, however, such as surgery, heart attacks, infections, fractures, and even sprained ankles can lead to RSD/CRPS. The precipitating injury may be so minor that the individual does not even recall sustaining an injury. Some other precipitants include, but are not limited to drug exposure, stroke with hemiplegia, and cervical spondylosis.

Normally, the nerves send pain signals through the spinal cord to the brain. With RSD/CRPS, problems arise when the spinal cord begins to send confusing signals to the brain, as well as to the injured area. These signals interfere with blood flow and sensory signals, often resulting in extreme pain. Immune response can be triggered causing sweating, discoloration, inflammation, temperature changes, and muscle spasms.

Treatment can lead to dramatic improvement and remission is possible and most effective within the first three months of symptoms. Clinical studies have shown that a delay in treatment may cause symptoms to worsen, resulting in long-term and even permanent physical and psychological problems. Over time, the condition can often become irreversible once the affected limb becomes cold and pale, undergoes skin and nail changes, and muscle spasms and tightening occurs. At this stage, available treatments tend to manage the underlying symptoms rather than treating the disorder directly.

Patient education and activity programs designed to increase mobility and promote use of affected area are considered the most important treatment for RSD/CRPS. Pain reducing, anti-inflammatory, as well as  psychotropic medications such as anti-depressants, antiepileptic drugs, muscle relaxants, and other drugs that produce generalized reductions in sympathetic outflow may also be used to treat the syndrome.  Surgery is also an available treatment for some patients.

More medical information on RSD/CRPS is available at http://www.mayoclinic.com and http://www.rsdfoundation.org.  More information can be found in “Titles II and XVI: Evaluating Cases Involving Reflex Sympathetic Dystrophy Syndrome/Complex Regional Pain Syndrome” [Social Security Ruling (SSR 03-02p)].

According to the provisions of SSR 03-02p, in a Social Security disability evaluation, RSD/CRPS is established in the presence of persistent complaints of pain that are typically out of proportion to the severity of any documented precipitating injury. To constitute a medically determinable impairment, one or more of the clinically documented signs of the syndrome in the affected region at any time following the documented precipitant must be present. These symptoms include swelling, abnormal hair or nail growth, osteoporosis, involuntary movements of the affected region of the initial injury, or autonomic instability in the form of changes in skin color or texture, decreased or excessive sweating, changes in skin temperature, or abnormal pilomotor erection (goosebumps).

In cases where RSD/CRPS is alleged, SSR 03-02p states that documentation of medical signs or laboratory findings since the date of the precipitating injury is critical in establishing a medically determinable impairment. The Ruling states that since conflicting evidence in the medical record is not unusual in cases of RSD/CRPS due to the transitory nature and complicated diagnostic process involved, clarification of any such conflicts in the medical evidence should be sought first from the individual’s treating physician or other medical sources.

When evaluating duration and severity, as well as residual functional capacity (RFC), the SSR states that effects of chronic pain and use of pain medications must be carefully considered because they may affect the patient’s ability to maintain concentration/attention, adversely affect mood and behavior, and slow motor reactions times.  These factors can interfere with an individual’s ability to sustain work activity.

If an individual’s statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not sustained by medical evidence, SSR 03-02p states that an Administrative Law Judge (ALJ) must make a finding on the credibility of the individual’s statements based on a consideration of the entire case record, including the individual’s statements. RSDS/CRPS is not a listed impairment but, according to the provisions of the SSR, specific findings should be compared to any pertinent listing to determine if a medical equivalence may exists or whether the individual’s impairment(s) meets or equals the severity of a mental listing through psychological manifestations related to the syndrome. In determining RFC, all of the individual’s symptoms must be considered in deciding how such symptoms may affect functional capacities and the usual vocational considerations (see 20 C.F.R. 404.1560-404.1569a and 416.960-416.969a) should be followed to determine the individual’s ability to perform work.

According to SSR 03-02p, third party information is often critical in deciding the individual’s credibility, including but not limited to; information from friends, neighbors, relatives, etc; statements from past employers, rehabilitation counselors, or teachers about the individual’s impairments and limitations; statements from other practitioners with knowledge of the patient; statements from other sources with knowledge of the individual’s ability to function in daily activities; and the individual’s own record of his or her impairment and its impact in function over time. In accordance with SSR 96-7p, when additional information is needed to assess the credibility of the individual’s statements about symptoms, the ALJ must make every reasonable effort to obtain additional information that could shed light on the credibility of those statements.

Albany Law School summer intern Patrick Manning researched and wrote this informative article.