How Does the Social Security Administration Decide if I Qualify for Disability Benefits for RSDS / CRPS?
If you have reflex sympathetic dystrophy syndrome, Social Security disability benefits may be available to you. To determine whether you are disabled by your reflex sympathetic dystrophy syndrome (also called complex regional pain syndrome), the Social Security Administration will consider whether your condition qualifies as a severe medically determinable impairment at Step 2 of the Sequential Evaluation Process. See RSDS / CRPS as a Medically Determinable Severe Impairment. If your reflex sympathetic dystrophy/complex regional pain syndrome qualifies at Step 2, the Social Security Administration next considers whether your condition is severe enough to equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for RSDS / CRPS by Meeting a Listing.
If your reflex sympathetic dystrophy/complex regional pain syndrome is not severe enough to equal a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your condition), to determine whether you qualify for benefits atStep 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for RSDS / CRPS.
About RSDS / CRPS and Disability
RSDS stands for reflex sympathetic dystrophy syndrome. CRPS stands for complex regional pain syndrome. RSDS and CRPS are two names for the same condition. RSDS / CRPS is a chronic, progressive neurological syndrome, characterized by severe pain, swelling, and changes in the skin.
The National Institute of Neurological Disorders and Stroke (NINDS) has defined RSDS as “a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems.”
RSDS usually affects one of the extremities (arms, legs, hands, or feet). The primary symptom is intense, continuous pain. Other symptoms include:
- Increased skin sensitivity.
- Skin temperature changes (warmer or cooler than opposing extremity).
- Skin color changes (blotchy, purple, pale, red).
- Skin texture changes (shiny, thin, sweaty).
- Changes in nail and hair growth patterns.
- Stiffness and swelling in affected joints.
- Decreased ability to move affected extremity.
The cause of RSDS/CPRS is unknown. Sometimes the syndrome is precipitated by injury and surgery, but some cases have no demonstrable injury to the original site.
RSDS / CRPS as a Medically Determinable Severe Impairment
You must have a medically determinable impairment that is severe to satisfyStep 2 of the Sequential Evaluation Process. The Social Security Administration has issued a ruling that focuses on proof that RSDS / CRPS is a medically determinable impairment. Below are some pertinent excerpts from that ruling.
Description of 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 Is RSDS / CRPS Identified as a Medically Determinable Impairment?
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.
Winning Social Security Disability Benefits for RSDS / CRPS by Equaling a Listing
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration considers whether your impairment is severe enough to meet or a listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that the Social Security Administration presumes would prevent a person from performing substantial work. If your impairment is severe enough to meet or equal a listing, you will be considered disabled.
The Social Security Administration has no listing for RSDS / CRPS. Since RSDS / CRPS is not a listed impairment, you cannot be found to meet a listed impairment based on your RSDS/ CRPS alone. However, the specific findings in your case should be compared to any pertinent listing to determine whether “medical equivalence” may exist. In other words, you may be entitled to Social Security disability benefits if the severity of your condition equals an existing listing for a different impairment.
If you have psychological problems related to RSDS / CRPS, they should be evaluated under the mental disorders listings. The Social Security Administration should consider whether your impairments meet or equal the severity of a mental listing. See Can I Get Social Security Disability Benefits for Depression, Bipolar Disorder, or Mania? and Can I Get Social Security Disability Benefits for Anxiety, Phobias, Panic Attacks, Obsessive Compulsive Disorder, or PTSD?
Residual Functional Capacity Assessment for RSDS / CRPS
What Is RFC?
If your RSDS / CRPS is not severe enough to equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process.
RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary workin spite of your impairments. An RFC for mental impairments is expressed in terms of whether Social Security Administration believes the claimant can do skilled, semi-skilled, or unskilled work in spite of impairments, or whether the claimant cannot even do unskilled work. The lower your RFC, the less the Social Security Administration believes you can do.
RSDS / CRPS and Residual Functional Capacity
If you have RSDS / CRPS, you may have significant residual limitations that could potentially result in allowance of your claim.
The Social Security Administration has issued a ruling on RSDS / CRPS that provides guidance to Social Security Administration adjudicators about what to consider in assessing a claimant’s RFC. In determining your RFC, the Social Security Administration adjudicator should consider all of your symptoms in deciding how they may affect your ability to function. Careful consideration should be given to the effects of pain and its treatment on your capacity to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis.
Opinions from your treating doctors concerning the effects of RSDS / CRPS on your 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 your impairments and your RFC. See Getting Your Doctor’s Opinion About What You Can Still Do.
Any information a medical source is able to provide contrasting your medical condition and functional capacities since the onset of RSDS / CRPS with your status before its onset is helpful to the adjudicator in evaluating your impairments and their functional consequences.
Evidence from medical practitioners who have provided services to you is often critical in deciding your credibility.
Statements from people who know you can help the adjudicator to assess your ability to function on a day-to-day basis. These statements can also help show how your condition has changed over time. Such evidence includes, but is not limited to:
- Information from neighbors, friends, relatives, or clergy.
- Statements from past employers, rehabilitation counselors, or teachers about your impairments and their effects on how your function in the work place, rehabilitation facility, or educational institution.
- Statements from health care professional, other than doctors, who know you, such as nurse-practitioners, physicians’ assistants, naturopaths, therapists, social workers, and chiropractors.
- Your own record (such as a diary, journal, or notes) of your impairments and their impact on function over time.
Getting Your Doctor’s Opinion About What You Can Still Do
Your Doctor’s Medical Opinion Can Help You Qualify for Social Security Disability Benefits
The Social Security Administration’s job is to determine if you are disabled, a legal conclusion based on your age, education and work experience and medical evidence. Your doctor’s role is to provide the Social Security Administration with information concerning the degree of your medical impairment. Your doctor’s description of your capacity for work is called a medical source statement and the Social Security Administration’s conclusion about your work capacity is called a residual functional capacity assessment. Residual functional capacity is what you can still do despite your limitations. The Social Security Administration asks that medical source statements include a statement about what you can still do despite your impairments.
The Social Security Administration must consider your treating doctor’s opinion and, under appropriate circumstances, give it controlling weight.
The Social Security Administration evaluates the weight to be given your doctor’s opinion by considering:
- The nature and extent of the treatment relationship between you and your doctor.
- How well your doctor knows you.
- The number of times your doctor has seen you.
- Whether your doctor has obtained a detailed picture over time of your impairment.
- Your doctor’s specialization.
- The kinds and extent of examinations and testing performed by or ordered by your doctor.
- The quality of your doctor’s explanation of your impairment.
- The degree to which your doctor’s opinion is supported by relevant evidence, particularly medically acceptable clinical and laboratory diagnostic techniques.
- How consistent your doctor’s opinion is with other evidence.
When to Ask Your Doctor for an Opinion
If your application for Social Security disability benefits has been denied and you have appealed, you should get a medical source statement (your doctor’s opinion about what you can still do) from your doctor to use as evidence at the hearing.
When is the best time to request an opinion from your doctor? Many disability attorneys wait until they have reviewed the file and the hearing is scheduled before requesting an opinion from the treating doctor. This has two advantages.
- First, by waiting until your attorney has fully reviewed the file, he or she will be able to refine the theory of why you cannot work and will be better able to seek support for this theory from the treating doctor.
- Second, the report will be fresh at the time of the hearing.
But this approach also has some disadvantages.
- When there is a long time between the time your attorney first sees you and the time of the hearing, a lot of things can happen. You can improve and go back to work. Your lawyer can still seek evidence that you were disabled for a certain length of time. But then your lawyer will be asking the doctor to describe your ability to work at some time in the past, something that not all doctors are good at.
- You might change doctors, or worse yet, stop seeing doctors altogether because your medical insurance has run out. When your attorney writes to a doctor who has not seen you recently, your attorney runs the risk that the doctor will be reluctant to complete the form. Doctors seem much more willing to provide opinions about current patients than about patients whom they have not seen for a long time.
Here is an alternative. Suggest that your attorney request your doctor to complete a medical opinion form on the day you retain your attorney. This will provide a snapshot description of your residual functional capacity (RFC) early in the case. If you improve and return to work, the description of your RFC provides a basis for showing that you were disabled for a specific period. If you change doctors, your attorney can get an opinion from the new doctor, too. If you stop seeing doctors, at least your attorney has one treating doctor opinion and can present your testimony at the hearing to establish that you have not improved.
If you continue seeing the doctor but it has been a long time since the doctor’s opinion was obtained, just before the hearing your attorney can send the doctor a copy of the form completed earlier, along with a blank form and a cover letter asking the doctor to complete a new form if your condition has changed significantly. If not, your attorney can ask the doctor to send a one-line letter that says there have been no significant changes since the date the earlier form was completed.
There are times, though, that your attorney needs to consider not requesting a report early in the case.
- First, depending on the impairment, if you have not been disabled for twelve months, it is usually better that your attorney wait until the twelve-month duration requirement is met.
- Second, if you just began seeing a new doctor, it is usually best to wait until the doctor is more familiar with your condition before requesting an opinion.
- Third, if there are competing diagnoses or other diagnostic uncertainties, it is usually best that your attorney wait until the medical issues are resolved before requesting an opinion.
- Fourth, a really difficult judgment is involved if your medical history has many ups and downs, e.g., several acute phases, perhaps including hospitalizations, followed by significant improvement. Your attorney needs to request an opinion at a time when the treating doctor will have the best longitudinal perspective on your impairment.
Medical Opinion Forms
Medical opinion forms can be great time savers for both your attorney and your doctor, but they must be used with care. Forms may not be appropriate at all in complex cases; and they need to be supplemented in many cases so that all issues are addressed. The best forms are clear and complete but not too long.