Persons suffering from Reflex Sympathetic Dystrophy Syndrome (RSDS) or Complex Regional Pain Syndrome ("RSDS" will be used for both in this discussion) who are seeking Social Security Disability benefits received assistance with the issuance of a Social Security Ruling on October 20, 2003. This Ruling, entitled: "Title II and XVI: Evaluating Cases Involving Reflex Sympathetic Dystrophy Syndrome/Complex Regional Pain Syndrome" outlines binding criteria for both proving the disease, and determining its impact on function, in Social Security Disability claims. This Ruling will also impact on claims evaluated by the Railroad Retirement Board.
The Social Security Act is defined by formal Regulations. The Regulations are supplemented by the Social Security Administration's Rulings. These Rulings are binding on all decision-makers in the disability process and are given significant weight by federal court judges. Ruling 03-2p significantly clears up issues relating to the proof of RSDS claims.
The Social Security Act requires Claimants to provide medical proof of the inability to perform any substantial gainful activity because of a medically determinable impairment that has lasted at least 12 months, or is expected to last 12 months, or result in death.
Basically this means that Claimant must:
Prove the existence of medical impairments;
Prove that those problems produce severe symptoms;
And, prove that, considering age, education, work history and remaining ability to function, those symptoms make it is impossible to "do" any type of work activity, for a period of at least 12 months.
The Regulations place strong emphasis on the use of "objective medical evidence", i.e. test results, clinical findings, data that cannot be "faked". RSDS claims have always been problematic because of the difficulty in proving the existence of the disease, and then in proving the severity of the symptoms. Since there is no test which is determinative for RSDS, and the pain complaints also cannot be proven, these cases have been difficult to prove. Most records for RSDS patients focus on "subjective symptoms" such as "I hurt" and this type of evidence is given much less weight as it cannot be scientifically proven.
SOCIAL SECURITY RULING 003-2P
The Ruling provides guidelines for decision-makers for both determining the existence of the impairment and for determining its impact on function.
A. Does A Medically Determinable Impairment Exist?
The Ruling notes that RSDS is a chronic pain syndrome usually resulting from trauma to an extremity. As in any Social Security claim, the analysis starts with the findings contained in the treating medical records. For diagnostic purposes (proving the existence of the medical impairment) the Ruling requires the presence of complaints of "persistent, intense pain that results in impaired mobility of the affected region." These complaints must be associated with clinical findings of:
Autonomic instability (changes in skin color, changes in sweating, skin temperature change, gooseflesh)
Abnormal hair or nail growth
Involuntary movements of the affected region of the initial injury.
These types of findings must be in the records of the treating specialist. The focus will be on the 12-month period prior to the date of application, depending on the facts of the claim.
The Ruling does note that this is a progressive disorder, and that symptoms do wax and wane. The focus is on "longitudinal treatment records" documenting persistent limiting pain over a sustained period of time. The other clinical findings may be transient. The Ruling also notes that there may be conflicting diagnoses.
A very key feature of the Ruling is its re-emphasis on the "treating physician rule." This concept provides that the findings and opinions of the treating specialist are entitled to deference, and possibly controlling weight, if they are supported and consistent with the clinical record. This again emphasizes the importance of consistent medical care with the appropriate specialists.
B. How Is The Severity Of The Condition Evaluated?
The Ruling provides guidelines for evaluating the severity of the pain in an RSDS claim. Again the focus is on the treating physician's medical records. The Ruling notes that symptoms will vary — sometimes stable, sometimes better, sometimes worse. A longitudinal view of the records is important given the nature of the disease.
Decision-makers are instructed to look at the nature of type of medications prescribed, the impact on attention and concentration, cognition, mood and behavior. Depression and anxiety may be present and disabling and need to be considered. There may be findings of reduced motor reaction times. Information about the response to treatment is important in determining whether the condition will be disabling for the required 12-month period.
The Ruling notes that other symptoms associated with RSDS may impact on the ability to work such as extreme sensitivity to touch or pressure and abnormal reactions to hot and cold.
As with any case based on symptoms focused upon symptoms — such as pain or fatigue — the claim often boils down to the credibility of the Claimant. Careful preparation of the Daily Activities forms, preparation for consultative examinations and careful review of the issues prior to any testimony at an ALJ hearing, can make a significant difference in the outcome.
The Ruling notes that the individual's statements, the treating physician's records and opinions, and the statements of knowledgeable third parties are all to be used in determining credibility. Noted third-party sources include neighbors, friends, relatives, clergy, past employers, teachers, nurse-practitioners, social workers, therapists, chiropractors and others with knowledge of the individual's ability to function in daily activities.
Social Security Ruling 03-2p is a significant statement for persons suffering from RSDS. It provides concrete, and fairly liberal, guidelines for Claimants and their representatives to use when proving the existence and severity of RSDS on the ability to sustain work activity. This should lead to more approvals for people suffering from this debilitating impairment.
Jeffrey A. Rabin
Jeffrey A. Rabin & Associates, Ltd.
636 South Des Plaines River Road
Des Plaines, IL 60015