crpsa_ssdi_ruling_on

Reflex Sympathetic Dystrophy Syndrome
Complex Regional Pain Syndrome

RSD(S)-CRPS Advisory

SSDI Ruling on RSD

SOCIAL SECURITY DISABILITY

Social Security Disability Ruling on RSDS Part One

Social Security Ruling on Reflex Sympathetic Dystrophy Passes!

From the Federal Register, October 20, 2003 (Volume 68, Number 202).

This Ruling is effective October 20, 2003.
What follows is the new Social Security Administration Ruling concerning Reflex
Sympathetic Dystrophy Syndrome. I will and condense it a little for sake of space.

This ruling was passed on from Carolyn Kiefer, Office of Disability Programs, Social
Security Administration. Our extreme thanks go out to her and to all those who worked on
getting this ruling passed; including the RSDSA who have worked on it for two years now.

This ruling explains Social Security policies for developing and evaluating Title II and Title
XVI claims for disability 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.

SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social
Security gives notice of Social Security

[[Page 59972]]

Ruling, SSR 03-2p. This Ruling explains the policies of the Social Security Administration
for developing and evaluating title II and title XVI claims for disability 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.

EFFECTIVE DATE: October 20, 2003.

SUPPLEMENTARY INFORMATION: Although we are not required to do so pursuant to 5
U.S.C. 552(a)(1) and (a)(2), we are publishing this Social Security Ruling in accordance
with 20 CFR 402.35(b)(1).

Social Security Rulings make available to the public precedential decisions relating to the
Federal old-age, survivors, disability, supplemental security income, and black lung
benefits programs. Social Security Rulings may be based on case decisions made at all
administrative levels of adjudication, Federal court decisions, Commissioner's decisions,
opinions of the Office of the General Counsel, and policy interpretations of the law and
regulations.

Although Social Security Rulings do not have the same force and effect as the statute or
regulations, they are binding on all components of the Social Security Administration, in
accordance with 20 CFR 402.35(b)(1), and are relied upon as precedents in adjudicating
cases.

If this Social Security Ruling is later superseded, modified, or rescinded, we will publish a
notice in the Federal Register to that effect. (Catalog of Federal Domestic Assistance,
Program Nos. 96.001 Social Security--Disability Insurance; 96.006 Supplemental Security
Income)

Dated: October 8, 2003.
Jo Anne B. Barnhart,
Commissioner of Social Security.

Policy Interpretation Ruling

Titles II and XVI: Evaluating Cases Involving Reflex Sympathetic Dystrophy
Syndrome/Complex Regional Pain Syndrome

Purpose: To explain the policies of the Social Security Administration for developing and
evaluating title II and title XVI claims for disability 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.

Citations (Authority): Sections 216(i), 223(d), 1614(a)(3), 1614(a)(4) and 1614(c) of the
Social Security Act (the Act), as amended; Regulations No. 4, subpart P, sections
404.1502, 404.1505, 404.1508-404.1509, 404.1511-404.1513, 404.1520, 404.1520a,
404.1521, 404.1523, 404.1526-404.1530, 404.1545-404.1546, 404.1560-404.1569a; and
404.1593-404.1594 and appendix 1; and Regulations No. 16, subpart I, sections 416.902,
416.905, 416.906, 416.908-416.909, 416.911-416.913, 416.920, 416.920a, 416.921,
416.923, 416.924, 416.924a-416.924c, 416.925, 416.926, 416.926a, 416.927-416.930,
416.945-416.946, 416.960- 416.969a, 416.987, and 416.993-416.994a.

Introduction: 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.

Policy Interpretation

SOCIAL SECURITY RULING ON RSDS (Part Two)

Policy Interpretation

What Is RSDS/CRPS?

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 timeframes. 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.

What Is a Medically Determinable Impairment?

Sections 216(i) and 1614(a)(3) of the Act define "disability''

1. as the inability to engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment (or combination of impairments) which can be
expected to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months.

---1/ Except for statutory blindness.

--- 2/For individuals under age 18 claiming benefits under title XVI, disability will be
established if the individual is suffering from a medically determinable physical or mental
impairment (or combination of impairments) that results in ``marked and severe functional
limitations.''

See section 1614(a)(3)(C) of the Act and 20 CFR 416.906. However, for clarity, the
following discussions refer only to claims of individuals claiming disability benefits under
title II and individuals age 18 or older claiming disability benefits under title XVI.

It should be understood that references in this Ruling to the ability to do substantial gainful
activity, ``RFC,'' and other terms and rules that are applicable only to title II disability claims
and title XVI disability claims of individuals age 18 or older are also intended to refer to
appropriate terms and rules applicable in determining disability for individuals under age 18
under title XVI.

Sections 223(d)(3) and 1614(a)(3)(D) of the Act, and 20 CFR 404.1508 and 416.908,
require that impairment result from anatomical, physiological, or psychological
abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic
techniques. The Act and regulations further require that impairment be established by
medical evidence that consists of signs, symptoms, and laboratory findings, and not only by
an individual's statement of symptoms.

How Is RSDS/CRPS Identified as a Medically Determinable Impairment?

RSDS/CRPS constitutes a medically determinable impairment when it is documented by
appropriate medical signs, symptoms, and laboratory findings, as discussed above.
RSDS/CRPS may be the basis for a finding of ``disability.'' Disability may not be established
on the basis of an individual's statement of symptoms alone.

For purposes of Social Security disability evaluation, RSDS/CRPS can be 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 adjudicators can reliably determine that RSDS/CRPS is
present and constitutes a medically determinable impairment.
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, and do not affect a finding that a medically determinable
impairment is present.

SS RULING ON RSDS (Part Three)

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 medically determinable impairment.

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.

Generally, evidence for the 12-month period preceding the month of application should be
obtained, unless there is reason to believe that development of an earlier period is necessary,
the alleged onset of disability is less than 12 months before the date of the application, or a
fully favorable determination can be made with less evidence.

If the adjudicator finds that the evidence is inadequate to determine whether the individual is
disabled, he or she must first recontact the individual's treating or other medical source(s)
to determine whether the additional information needed is readily available, in accordance
with 20 CFR 404.1512 and 416.912.

Only after the adjudicator determines that the information is not readily available from the
individual's health care provider(s), or that the necessary information or clarification cannot
be sought from the individual's health care provider(s), should the adjudicator proceed to
arrange for a consultative examination(s) in accordance with 20 CFR 404.1519a and
416.919a.

The type of consultative examination(s) purchased will depend on the nature of the
individual's symptoms and the extent of the evidence already in the case record.

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. Clarification of any such conflicts in the
medical evidence should be sought first from the individual's treating or other medical
sources.

Medical opinions from treating sources about the nature and severity of an individual's
impairment(s) are entitled to deference and may be entitled to controlling weight.

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 adjudicator will give it controlling weight.

(See SSR 96-2p, "Titles II and XVI: Giving Controlling Weight to Treating Source Medical
Opinions,'' and SSR 96-5p, "Titles II and XVI: Medical Source Opinions on Issues

Reserved to the Commissioner

--- 3\ A medical source opinion that an individual is "disabled'' or "unable to work,'' has an
impairment(s) that meets or equals the requirements of a listing, has a particular residual
functional capacity (RFC), that concerns whether an individual's RFC prevents him or her
from doing past relevant work, or that concerns the application of vocational factors, is an
opinion on an issue reserved to the Commissioner.

Every such opinion must still be considered in adjudicating a disability claim; however, the
adjudicator will not give any special significance to such an opinion because of its source.
See SSR 96-5p for an additional discussion of this issue.

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 must
be carefully considered.

When the alleged onset of disability secondary to RSDS/CRPS occurred less than 12
months before adjudication, the adjudicator must evaluate the available medical
evidence and project the degree of impairment severity that is likely to exist at the
end of 12 months.

Information about treatment and response to treatment, as well as any medical source
opinions about the individual's prognosis at the end of 12 months, are helpful in deciding
whether the medically determinable impairment is expected to be of disabling severity for at
least 12 consecutive months.

In those cases in which an individual is found disabled based on RSDS/CRPS, but medical
improvement is anticipated, the adjudicator should schedule an appropriate medical
reexamination date consistent with the information indicating the likelihood of medical
improvement.

SS RULING ON RSDS (Final Part)

In accordance with SSR 96-7p, ``Titles II and XVI: Evaluation of Symptoms In Disability
Claims: Assessing The Credibility of An Individual's Statements,'' when additional
information is needed to assess the credibility of the individual's statements about symptoms
and their effects, the adjudicator must make every reasonable effort to obtain additional
information that could shed light on the credibility of the individual's statements.

If the adjudicator determines that the individual's impairment(s) precludes the performance
of past relevant work (or if there was no past relevant work), a finding must be made about
the individual's ability to perform other work. The usual vocational considerations (see 20
CFR 404.1560-404.1569a and 416.960-416.969a) must be followed in determining the
individual's ability to perform other work. See also SSR 96-8p, ``Titles II and XVI:
Assessing Residual Functional Capacity in Initial Claims.''

Many individuals with RSDS/CRPS are ``younger individuals'' ages 18 through 49 (see 20
CFR 404.1563 and 416.963). Age, education, and work experience are not usually
considered to limit significantly the ability of individuals under age 50 to make an adjustment
to other work, including unskilled sedentary work.

\5\ However, a finding of ``disabled'' is not precluded for those individuals under age 50
who do not meet all of the criteria of a specific rule and who do not have the ability to
perform a full range of sedentary work. The conclusion about whether such individuals are
disabled will depend primarily on the nature and extent of their functional limitations or
restrictions.

Thus, if it is determined that an individual is able to do less than the full range of sedentary
work, refer to SSR 96-9p, ``Titles II and XVI: Determining Capability to Do Other Work--
Implications of a Residual Functional Capacity for Less Than a Full Range of Sedentary
Work.'' As explained in that Ruling, whether the individual will be able to make an
adjustment to other work requires

[[Page 59976]]

adjudicative judgment regarding factors such as the type and extent of the individual's
limitations or restrictions and the extent of the erosion of the occupational base for
sedentary work.

5\ However, ``younger individuals'' age 45-49 who are unable to communicate in English or
who are illiterate in English, whose past work was unskilled (or who had no past relevant
work), or who have no transferable skills, and who are limited to a full range of sedentary
work must be found disabled under rule 201.17 in Table No. 1 of appendix 2, of the
Medical-Vocational Guidelines in 20 CFR part 404.

Effective Date: This Ruling is effective on the date of its publication in the Federal
Register.

Cross-References: SSR 96-2p, ``Titles II and XVI: Giving Controlling Weight to Treating
Source Medical Opinions,'' SSR 96-3p, ``Titles II and XVI: Considering Allegations of Pain
and Other Symptoms in Determining Whether a Medically Determinable Impairment is
Severe,'' SSR 96-5p, ``Titles II and XVI: Medical Source Opinions on Issues Reserved to
the Commissioner,'' SSR 96-7p, ``Titles II and XVI: Evaluation of Symptoms in Disability
Claims: Assessing the Credibility of an Individual's Statements,'' SSR 96-8p, ``Titles II and
XVI: Assessing Residual Functional Capacity in Initial Claims,'' and SSR 96- 9p, ``Titles II
and XVI: Determining Capability to Do Other Work-- Implications of a Residual Functional
Capacity for Less Than a Full Range of Sedentary Work.''

[FR Doc. 03-26332 Filed 10-17-03; 8:45 am] BILLING CODE 4910-02-U

For every hope you pray...
...You pay the price.