[Federal Register: October 20, 2003 (Volume 68, Number 202)/Notices]
EFFECTIVE DATE: October 20, 2003
Policy Interpretation Ruling
SSR 03-2p: Titles II and XVI: Evaluating Cases Involving Reflex Sympathetic Dystrophy Syndrome/Complex Regional Pain Syndrome
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.
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.
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:
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);
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.
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.
What Is a Medically Determinable Impairment?
Sections 216(i) and 1614(a)(3) of the Act define “disability” 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.
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:
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);
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.
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.”)
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.
How Is RSDS/CRPS Evaluated?
Claims in which the individual alleges RSDS/CRPS are adjudicated using the sequential evaluation process, just as for any other impairment. Because finding that RSDS/CRPS is a medically determinable impairment requires the presence of chronic pain and one or more clinically documented signs in the affected region, the adjudicator can reliably find that pain is an expected symptom in this disorder. Other symptoms, including such things as extreme sensitivity to touch or pressure, or abnormal sensations of heat or cold, can also be associated with this disorder. Given that a variety of symptoms can be associated with RSDS/CRPS, once the disorder has been established as a medically determinable impairment, the 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 must 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 finding a medically determinable impairment, once the existence of a medically determinable impairment has been established, 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. If the adjudicator finds that 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, a “severe” impairment must be found to exist. See SSR 96-3p, “Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe” and SSR 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements.”
Proceeding with the sequential evaluation process, when an individual is found to have a medically determinable impairment that is “severe,” the adjudicator must next consider whether the individual's impairment(s) meets or equals the requirements of the Listing of Impairments contained in appendix 1, subpart P of 20 CFR part 404. Since RSDS/CRPS is not a listed impairment, an individual with RSDS/ CRPS alone cannot be found to have an impairment that meets the requirements of a listed impairment. However, the specific findings in each case should be compared to any pertinent listing to determine whether medical equivalence may exist. Psychological manifestations related to RSDS/CRPS should be evaluated under the mental disorders listings, and consideration should be given as to whether the individual's impairment(s) meets or equals the severity of a mental listing.
For those cases in which the individual's impairment(s) does not meet or equal the listings, an assessment of RFC must be made, and adjudication must proceed to the fourth and, if necessary, the fifth step of the sequential evaluation process. 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. See SSR 96-7p, “Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual's Statements” and SSR 96-8p, “Titles II and XVI: Assessing Residual Functional Capacity in Initial Claims.”
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 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.
In cases involving RSDS/CRPS, third-party information, including evidence from medical practitioners who have provided services to the individual, and who may or may not be “acceptable medical sources,” is often critical in deciding the individual's credibility. Information other than an individual's allegations and reports from the individual's treating sources helps to assess an individual's ability to function on a day-to-day basis and helps to depict the individual's capacities over a period of time, thus serving to establish a longitudinal picture of the individual's status. Such evidence includes, but is not limited to:
Information from neighbors, friends, relatives, or clergy;
Statements from such individuals as past employers, rehabilitation counselors, or teachers about the individual's impairment(s) and the effects of the impairment(s) on the individual's functioning in the work place, rehabilitation facility, or educational institution;
Statements from other practitioners with knowledge of the individual, e.g., nurse-practitioners, physicians' assistants, naturopaths, therapists, social workers, and chiropractors;
Statements from other sources with knowledge of the individual's ability to function in daily activities; and
The individual's own record (such as a diary, journal, or notes) of his or her own impairment(s) and its impact on function over time.
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. 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 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.
This Ruling is effective on the date of its publication in the Federal Register.
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.”
 Except for statutory blindness.
 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.
 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.
 In evaluating title XVI claims for disability benefits for individuals under age 18, consideration must be given to the possibility of finding functional equivalence based on the individual's impairment and related symptoms and their effects on whether the individual's impairment(s) results in marked and severe functional limitations.
 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.