Complex Regional Pain Syndrome (CRPS) is a debilitating condition sometimes associated with industrial injuries, and Qualified Medical Evaluators (QMEs) will encounter this in injury claims.
CRPS was formerly known as Reflex Sympathetic Dystrophy (RSD) and is characterized by severe, persistent pain that often affects one limb. It may be secondary to an injury or trauma, though can develop simply with immobilization or disuse. The most common inciting events are fractures, sprains, strains, soft tissue injury, limb immobilization, and surgery. Although more common in women, CRPS can occur in anyone at any age, with a peak at age 40 (1). CRPS entails dysfunction in the nervous system. CRPS is divided into two types:
- CRPS-I: Occurs without a direct nerve injury.
- CRPS-II: Follows a distinct nerve injury, formerly known as causalgia.
Symptoms include burning pain, swelling, and changes in skin color and temperature. The pain often spreads from the site of injury to a larger area and can lead to severe disability if not treated promptly. Although there is no specific, definitive screening test, CRPS is diagnosed based on clinical symptoms, medical history, standing imaging such as x-ray and MRI, bone scan, and sweat testing. Treatment usually involves a multidisciplinary approach, including pain management, physical therapy, and medications.
QMEs are required to determine if the applicant has received appropriate treatment for their condition. Despite legislative changes under SB 863, which shifted the authority for prior treatment decisions to Utilization Review (UR) and Independent Medical Review (IMR), the QME’s determination of need for continued care remains crucial. A QME will need to determine whether the applicant’s condition has been stabilized through adequate care, needs further care prior to maximal medical improvement, or needs allowance for future medical care after already at maximal medical improvement.
A QME report will influence UR and IMR decisions. A QME might encounter a chronic pain patient who has not received sufficient treatment per accepted guidelines. In such cases, the QME can document the need for further treatment, such as aggressive physical therapy with desensitization, or a pain rehabilitation program. These recommendations, backed by a thorough evaluation and adherence to guidelines, can support the approval of necessary treatments during the UR and IMR processes.
According to Chapter 18 of the AMA Guidelines Fifth Edition, QMEs can assess whether an additional pain impairment rating is warranted. Chronic pain conditions, like CRPS, may qualify for up to an extra 3% Whole Person Impairment (WPI) if the pain exceeds typical levels associated with the underlying condition. When providing an impairment rating for CRPS, a QME may use any generally accepted criteria for confirming CRPS diagnosis, as well as any table, method, or chapter within the “Four Corners” of the AMA Guides Fifth Edition that most accurately reflects the injured worker’s impairment by invoking Almaraz/Guzman. The Guides also provide an objective basis for rating CRPS, which can be found in Section 16.5e. QMEs must be adept at performing pain-related impairment assessments to justify add-ons or a more liberal approach to the rating appropriately, ensuring that the impairment ratings accurately reflect the applicant’s condition.
Impairment rating for Complex Regional Pain Syndrome (CRPS) involves different criteria for CRPS I and CRPS II. For CRPS I, which does not involve a specific peripheral nerve, the impairment rating is derived by assessing the upper extremity impairment from joint motion loss and sensory deficits/pain. The severity of these sensory deficits is graded based on interference with daily activities, and clinical judgment is used to select the appropriate percentage impairment. These values are combined to determine the total upper extremity impairment and then converted to whole person impairment using standard tables.
In contrast, CRPS II involves a specific sensory or mixed nerve. The impairment rating for CRPS II includes evaluating the upper extremity impairment from joint motion loss, sensory deficits/pain of the injured nerves, and motor deficits/loss of power. These values are combined to determine the total upper extremity impairment, which can be as severe as 100% in extreme cases. This combined impairment is then converted to whole person impairment. No additional impairment is assigned for decreased pinch or grip strength in either CRPS I or II.
A QME’s expertise in pain assessment and treatment remains vital in determining an applicant’s P&S status and influencing the UR and IMR processes. By staying informed about chronic pain protocols and effectively documenting their findings, QMEs can ensure that individuals with CRPS receive the necessary care and fair disability evaluations they deserve.
Resources:
- “Complex Regional Pain Syndrome.” National Institute of Neurological Disorders and Stroke , September 2020.
- American Medical Association. Guides to the Evaluation of Permanent Impairment, Fifth Edition. Edited by Linda Cocchiarella and Gunna B.J. Andersson. Newburyport: American Medical Association, 2001.