The Evolution of Workplace Injuries:
An Introduction to Documenting Complex Regional Pain Syndrome (CRPS) and Maximizing Recovery
By Laura Cunard Reis
Identification, Diagnosis and Treatment in Upper and Lower Extremity Crush Injuriesi
Injured workers often suffer from extreme and chronic pain as a result of their workplace injuries. Current state statute-based workers’ compensation systems do not allow for recovery of pain and suffering. This however was not the case during the earlier part of the 20th century when an injured workers’ remedy was in tort just like any other accident/injury case. Before these systems were implemented, injured workers had no right of recovery from their employer unless the employer was at fault. Unfortunately, this left many injured workers without a job and without medical treatment. As workers’ compensation systems evolved during the early 20th century, lawmakers throughout the United States enacted legislation wherein workplace injuries became no-fault, while simultaneously precluding recovery for pain and suffering. As a result, latter generations of injured workers have resolved claims with little to no compensation for ongoing future pain management.
How, then can an injured worker become more fully compensated for ongoing pain and suffering? The answer is documenting a comprehensive treatment plan including identification, diagnosis and future treatment of pain complexes. This is essential to ensure that clients receive a fair recovery. In recent history, legal and medial communities have focused on closed head injuries through documentation of non-specific head pain, neurological deficit and memory interruption, while ignoring chronic pain from injuries to other areas of the body. Although there are a substantial number of closed head injuries in the workplace, there are also a substantial number of crush-like injuries to the extremities. The injuries to the hands, arms, legs and feet are often treated as a minor bruise-like injuries (contusions). In reality, these injuries can be as complex and as costly from a medical expense perspective as closed head injuries due to the development of a pain disorder known as Complex Regional Pain Syndrome (CRPS), where pain spreads to other regions in the body, not just the site of trauma. This phenomenon is often overlooked by medial professionals not trained in pain management. An injured worker receiving immediate treatment from appropriate medial providers prior to the resolution of their claim is the first step to ensure that the injured worker receives full and fair workers’ compensation benefits.
Identification: What does it all mean?
Complex Regional Pain Syndrome (CRPS) is a pain disorder that frequently occurs in persons who sustain injury to an extremity. When a nerve ending is interrupted or irritated, pain signals run through the affected nerve, and, in extreme situations, throughout the body. Frequently, the pain signals do not follow a linear pattern and transfer to different bodily regions, like from the finger into the neck. For example, a crush injury to the finger can, in CRPS patients, lead to numbness in the neck. When CRPS develops, relatively simple injuries can often become catastrophic, especially for unskilled injured workers.
There are certain symptoms in and around the injured area identified with the development of CRPS. After the precipitating injury the injured are is generally overly sensitive to touch, swells easily and is subject to temperature variables. Spontaneous pain is present, often accompanied by decreased range of motion. Damaged nerves become ‘epileptic’ and nerve signals become confused, firing at will. If appropriate treatment is not received in the first six months following the original injury, the pain often becomes more intense, spreading throughout the extremity and resulting in the onset of muscle atrophy. Within one year post-injury, muscle atrophy results in decreased strength in the affected extremity and the skin becomes shiny and thin due to the loss of fat beneath the skin. Injured workers often develop psychological problems as CRPS develops.
The nomenclature for CRPS is often the source of confusion. CRPS is frequently referred to as Reflex Sympathetic Dystrophy (RSD), Sympathetically Maintained Pain (SMP) and Causalagia. It has also been referred to as Sudek’s atrophy. Today, most physicians agree that CRPS is the correct term for this disorder. CRPS cases specifically involve a disorder of the sympathetic nerve system generally brought about by trauma to an upper or lower extremity. This trauma often causes pain to the extent that the patient is frequently incapable of working and requires long-term medical intervention.
CRPS symptoms create a disturbance in the sympathetic part of the autonomic nervous system, comprising involuntary (reflex) operations, such as body temperatyre, respiration, heart rate, blood pressure and many other automatic functions. This system is also responsible for the body’s “fight or flight” defense mechanism; physicians believe a defect in this panic mechanism is the source of pain in CRPS sufferers. Sympathetic nerve signals run from the extremities to the cervical, thoracic and lumbar regions of the spinal cord, there they then ‘jump ship’ to the central vervous system and the brain and other major organs. Confused nerve signals in the neck can evven run to the optic nerve, distorting vision and facial movements. A key component of this syndrome is that the pain experienced is generally disproportionate to severity of the original injury.
Although medical and legal communities have recently become more focused on these pain disorders, their origins are not new. Causalagia stems from the Greek words “kausos,” literally defined as “to burn” and “algis,” meaning pain. Causalagia was first formally studied during the United States Civil War, where upper and lower extremity gunshot victims often complained of ‘transferred’ pain to other parts of their body. During this period Causalagia was classified as “major” and “minor.” Now, major Causalagia is referred to as Causalagia, while minor Causalagis is called RSD. The term RSD was first used by scientists in the mid-twentieth century and gained popularity in the medical community in the 1970’s.
According to the International Association for the Study of Pain, the distinction is that Causalagia is the result of a definite, concrete injury to a nerve, while RSD does not involve an injury to the actual nerve. Rather, RSD results from an internal injury that transfers pain to a nerve, resulting in irritation. In the case of RSD, the nerves are constricted rather than cut, making the condition difficult to diagnose, test and treat. This difficulty is compounded because there is no physiological damage to the actual nerve. There is no concrete cure for either syndrome, but Causalagia is more readily identifiable. It has been documented that crushed nerves rapidly trigger random growth of the nerve sprouts where severed nerves heal more slowly and carefully. Therefore, RSD patients recover more slowly than injured workers who suffer ‘more serious’ initial injuries.
The main types of injuries that lead to CRPS include finger, hand, toe or foot crush injuries, partial amputations, minor lacerations, blows to the hand with or without fracture, puncture wounds, sprains, fractures, burns, surgery or repetitive trauma. Although the physiological origin of CRPS remains uncertain, it is believed that, following trauma, damaged or irritated nerve endings sprout weaker tentacle-like nerve endings that are more susceptible to pain.
Diagnosis: How can we find what we cannot see?
Injured workers generally do not have medial training and occupational physicians are often discouraged from exploring new treatment options, resulting in misdiagnosis or, worse, a non-diagnosis of CRPS. In such case, a claimant may depend on his/her attorney to recommend appropriate medical care. The Social Security Administration (SSA) has stated that a finding of disability can be made if just one or more of the characteristic symptoms are consistently documented. Accordingly, CRPS should be considered in upper and lower extremity workers’ compensation injuries if some of the following symptoms occur:ii
Pain out of proportion to the accident or injury
Burning or aching pain
Swelling, joint tenderness or edema in the painful area
Decreased motor function
Changes in skin temperature (cold to hot or hot to cold) and/or skin color and/or skin texture of affected extremity and/or abnormal hair/nail growth
Muscle spasms or involuntary movements
Localized bone softening (osteoporosis)
Increased sweating of the affected extremity
Often a physician is forced to diagnose CRPS through a process of elimination, or through a “differential diagnosis.” As workers’ compensation trials frequently are not formally reported, many significant rulings in workers’ compensation related injuries stem from third-party personal injury actions, where an injured worker makes a claim for negligence against a tortfeasor other than the employer. A 2004 Wyoming ruliing stems from a workers’ compensation injury such as this and held that the treating neurologist’s diagnosis of RSD was proper ant that his testimony withstood a Daubert challenge as admissibility. Here, the injured worker’s temporal complaints of pain following the injury coupled woth the lack of a finding of any other medial condition to explain the resultant pain was sufficient to establish the existence of RSD.iii
The SSA breiefly addresses workers’ compensation claims as they pertain to workplace injuries in their ruling on RSD, now called CRPS, as follows: “In any workers’ compensation case, the claimant’s credibility is very important to the outcome. So, too, is the weight of conflicting medical evidence. This is particularly true in RSD cases, because, as indicated, objective evidence is often minimal, and employers will naturlaly look for explanations.”iv It should be noted that traumatic injuries are not the only thing that can bring about this condition. Degenerative joint disease and osteoarthritis can also lead to CRPS. It is, therefore, key to examine the client’s past medical history and scrutinize his/her credibility to avoid any argument by opposing counsel that the CRPS was not precipitated by the workplace injury.
In addition to diagnosing CRPS through documentation of symptoms, clinical tests can be performed to determine the severity of the pain complex. These tests include bone scans, EMGs and thermography. A bone scan pinpoints abnormalities in bone growth and, in the case of CERPS sufferers, deterioration. An EMG identifies neural transmission rates and abnormal neural activity in the affected extremity. A thermography, however, is the most concrete evidence of CRPS because it provides a “pictorial representation of heat emissions from the body.”v This type of CRPS documentation lends credibility to the injured worker’s complaints of pain after the underlying injury has resolved. Also, a physician may administer injections, such as sympathetic nerve blocks, in order to investigate a patient’s response to the interruption of the nerve signals – if the pain decreases when the injection is administered, CRPS is confirmed.
Patients with RSD may experience pain so severe that soft fabrics ‘burn’ the skin and make even the lightest touch unbearable. This “stocking glove” sensation, however, is largely psychological. For most injured workers, the pain syndrome is not quite as extreme, but is still debilitating. In the majority of these cases, the pain restricts day-to-day activities, such as sitting, walking and standing for long periods of time.
Early diagnosis and treatment in the first stage of CRPS inhibits development of residual symptoms, which are difficult and costly to treat effectively. For this reason, prompt treatment benefits all parties, including the insurance carrier. Failure to timely diagnose CRPS may even subject the physician to a malpractice action, as occurred in a 2001 New York ruling.vi Certainly in this situation, an ounce of diagnosis/prevention is worth a pound of cure. The SSA has opined that, “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 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 CRPS persist longer than six months in 50 percent of cases, but may last for years in cases where treatment is not successful.” It is estimated that two to fiver percent of patients with peripheral nerve injuries develop RSD. vii
Furthermore, many workers diagnosed with CRPS develop a psychological overlay due to their pain condition and become depressed and withdrawn. In extreme cases, the injured worker may even suffer from post-traumatic stress disorder. The main reason for this depression/withdrawal si that such injured workers are generally viewed as malingerers. In patients who are diagnosed with CRPS, it is essential that they receive treatment for both the physical and psychological components of their injury. In addition to avoiding strenuous jobs, injured workers who suffer from psychological injuries should avoid stressful workplace conditions.
We can help educate our clients on their condition once they are diagnosed with CRPS. RSD Alert, the International Research Foundation for RSD/CRPS, For Grace, the International Association for the Study of Pain (IASP), the Reflex Sympathetic Dystrophy Syndrome Association and the Workers’ Compensation Research Institute are some of the more prominent organizations that provide online information and education to CRPS sufferers.viii
Treatment: Can we fix this thing?
CRPS involves a complex diagnostic process. Because many of the symptoms are subjective, it can be helpful for the client to keep a journal documenting his/her pain to present to the physician. When this is provided to the physician, it may help assure that an appropriate diagnosis is rendered.
Treatment for CRPS consists of extensive physical therapy, psychological counseling, sympathetic nerve blocks, pharmaceutical intervention and implantation of neurostimulators. A last resort is surgical sympathectomy, where a portion of the stellate ganglion, a nerve cluster in the neck, is removed. Because of transferred pain signals, a physician frequently must administer injections in various regions of the body in order to provide relief. Pharmaceuticals helpful in the treatment of CRPS include antidepressants, antiepileptic medication, muscle relaxants, anti-imflammatory medication and narcotic pain medication. Even after the original injury heals, due to significant pharmaceutical intervention, the injured worker sis frequently unable to return to work due to his/her inability to react promptly, drive, operate machinery and even concentrate. This inability to function at a normal level can obviously have adverse effects on workplace safety. In extreme cases, amputation of the extremity has been warranted.
Types of Treament for CRPS ix
Physical therapy and psychological counseling
Cold compresses, hot wax application
Anti-inflammatory and narcotic medicines
Immobilization with a cast or splint
Stellate ganglion ultrasounds
Transcutaneous electrical nerve stimulation (TENS unit)
Sympathetic ganglion block (single and continuous)
Paravertebral sympathetic ganglionectomy
Guideline: Taking a lesson from the SSA
This article relies on the 2003 SSA guidelines for evaluating and diagnosing RSD and CRPS claims.x Even though the workers’ compensation systems are administratively based, there are no comprehensive guidelines for evaluating these types of pain syndrome claims. Many jurisdictions outline procedures and requirements for paralysis, strokes and hernias, but pain syndromes have been ignored. Therefore, the duty rests in the hands of injured workers, their medical proviers and their attorneys to document these conditions.xi
RSD and the Courts: Charting new territory
The court system is often unfamiliar with CRPS and related pain syndromes. As a result, the injured workers’ complaints of chronic pain have often been discounted or even totally ignored by the trier of fact. Therefore, medical documentation including expert reports/testimony are necessary and indispensable.
In 1992, the Court of Appeals of Georgia reversed the Superior Court’s decision that the claimant’s complaints of pain were unfounded and the claimant was capable of working in some capacity.xii In this case, the claimant suffered a upper extremity injury requiring elbow surgery. Subsequent to the surgery, the claimant returned to work for the employer in a light duty capacity for two hours, after which the claimant’s pain became too severe to continue working. The Administrative Law Judge (ALJ) agreed with the claimant and the employer appealed to the Full Board. The board sent the claimant to a doctor who made a finding of RSD, after which the board affirmed the ALJ’s ruling. The employer appealed again to the Superior Court held that there was no evidence to support a finding of ongoing disability; the Appellate Court reversed this finding. The Appellate Court held that the ALJ did not err in placing substantial weight on the claimant’s testimony. An opposite result occurred in a 1995 Georgia Court of Appeals case where the ALJ did not find that evidence presented supported a finding of disability, although evidence was presented subsequent to the original trial finding disability from RSD.xiii The lesson to be learned from these cases is that properly documenting and proving the injured workers’ CRPS condition in a timely manner enables triers of fact to become familiar with and consider the debilitating effects of this chronic pain syndrome.
Claimants are generally allowed to recover for permanent bodily impairment. In Georgia, an amputated index finger is statutorily valued at forty weeks of weekly income benefits for the worker’s permanent partial disability (PPD). In such a case, an injured worker with a compensation rate of $400.00 per week would receive $16,000 for this injury, in addition to the weekly income benefits he receives while out of work. It should be noted that the pain complexes are common in amputee cases, and that amputees often suffer from phantom pain associated with the lost extremity. This creates a need for future pain management wherein the cost of this future medical treatment will far exceed the scheduled PPD amount.
In a 2007 Kentucky Supreme Court case, the claimant sustained a crush injury with open fracture to his right distal finger.ixx He received less thatn one month of total disability and a 1 percent PPD rating. Four months later the worker sustained a crush injury to his left foot and developed CRPS. Treament for the foot injury included implantation of a neurostimulator and pain medication. The worker was subsequently diagnosed with resultant depression requiring psychological treatment. The treating physician assigned permanent work restrictions and a 39 percent PPD rating based on the foot and a 20 percent PPD rating based on depression.xx Had the doctors for the second injury ignored the claimant’s complaints fo pain and failed to perform additional testing, there would not have been a CRPS diagnosis, and, therefore, the worker would not have been fully compensated for his injuries.
A 2007 United States Court of Appeals ruling in Federal Employers Liability Act (FELS) case demonstrates the length of treatment often required to fully realize a peripheral nerve injury leading to the development of RSD.xxi An offshore worker crushed his big toe, injuring his peroneal nerve, when a valve fell on his foot at work in January of 2002. Although the fracture healed in approximately three weeks, he continued to experience tremendous pain. He subsequently sought treatment with a neurologist who diagnosed him with RSD and performed sympathetic nerve blocks. After his medical discharge in February of 2003, the worker’s condition continued to deteriorate. He was prescribed nerve pain medication in such high doses that he was unable to function. Thereafter, the worker sought treatment with a pain management physician. In 2004, this physician ordered the installation of a sciatic nerve catheter and peripheral nerve stimulator. In this case, the Superior Court awarded over $1,000,000 of the judgement for medical treatment, income benefits and vocational rehabilitation.xxii
The onset of symptoms from CRPS injuries is often delayed, which can allow a late-filed claim to still be viable. A 1994 Illinois ruling considered ignoring the defendant’s statute of limitation defense where the plaintiff’s RSD did not develop until after the statute expired for the original injury.xxiii Therefore, it is possible for untimely diagnosis if CRPS to toll the statute of limitation on an otherwise precluded claim.
Application: Proving your case
Identification, diagnosis and treatment of CRPS position your client to be made whole from both a medical and monetary standpoint. However, clients are often unwilling to pursue their workers’ compensation claim throughout the healing process due to numerous factors, including reduced income and intervention from the insurance carrier. Treating physicians and pain management specialists usually provide documentation of future treatment costs. More importantly, however, nurse practitioners or other medical providers knowledgeable in Current Procedural Terminology (CPT) codes are often better equipped to provide an accurate future cost analysis. The charge for this type of report is generally reasonable, and certainly necessary, in order to quantify future medical expenses.
In severe cases where the injured worker is heavily medicated or where physical mobility is restricted, the cost of home-care attendance and transportation expenses should be included in the evaluation. Vocational rehabilitation costs should also be included where CRPS permanently precludes injured workers from their ability to return to work. This strategy is somewhat similar to life care plans used in catastrophic tort cases.
Documenting the present value of future treatment places a current, tangible monetary value of the carriers risk rather than allowing a claims adjuster to write off future treatment expenses as vague, or worse, to dismiss the client’s pain management needs as non-compensable pain and suffering. These reports insure that elements important to proving the injured workers’ case are included in the process and are helpful in settlement evaluation and mediation. Proper documentation of all essential factors, including the full estimate of future medical care assists the trier of fact, the attorneys and the client in reaching a speedy and just resolution for the injured worker.
Laura Cunard Reis is a 2003 graduate of Emory University School of Law and a 2000 graduate of Boston College. Laura is the owner of ReisLaw, LLC in Atlanta, Georgia, where she focuses on litigating complex workers’ compensation claims.
i General sources consulted include Theodore S. Grabow, M.D. et al, Complex Regional Pain Syndromes: Terminology and Pathophysiology in Handbook of Pain Management ch. 46, 376 (C. David Tollison, Ph.D.ed., 2d ed., Williams and Wilkins 1994); C. Richard Chapman and Judith A. Turner, Psychological Aspects of Pain in Bonica’s Management of Pain ch. 6, 180 (John D. Loeser, M.D., ed., 3d ed., Lippincott Williams and Wilkins 2001); Nelson Hendler and Srinivasa N. Raja, Reflex Sympathetic Dystrophy and Sausalagia in Essentials of Pain Medicine and Regional Anesthesia ch. 39, 484 (Honorio T. Benzon, M.D. et al, eds., 2d ed., Elsevier Churchill Livingstone 2005); Michael Stanton-Hicks, Upper and Lower Extremity Pain in Practical Management of Pain ch. 19, 312 (P. Prithvi Raj, ed., 2d ed., Mosby Year Book 1992); and 19 Am.Jur. Proof of Facts 3d 179.
ii Mayrav Saar, Pain that Doesn’t Go Away: RSD Hurts So Much that Even Some Doctors Don’t Believe It, L6 The Seattle Times (July 20, 2003).
iii Easum V Miller, 2004 WY 73, 92 P.3d 794 (Wy. 2004).
iv 19 Am.Jur. Proof of Facts 3d 179 at 44.
v Evaluating Cases Involvint Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome, 2003 SSR LEXIS 2 (SSR 2003)
vi Valentine v. Lopez. 283 A.D.2d, 739 (3d Dep’t 2001).
vii Mayrav Saar, Pain that Doesn’t Go Away: RSD Hurts So Much that Even Some Doctors Son’t Believe It, L6 The Seattle Times (July 20, 2003)
ix Adapted from 19 Am.Jur. Proof of Facts 3d 179 section 8
x Evaluating Cases Involving Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome, 2003 SSR LEXIS 2 (SSR 2003)
xi In its ruling, the SSA found that in some instances of those diagnosed with RSD or CRPS, “the precipitating injury may be so minor that the individual does not even recall sustaining the injury”. Nevertheless, it has been determined that this situation can be the basis for a finding of total disability. Often, a similar situation exists in workers’ compensation claims, where the underlying injury has resolved but the client has residual pain symptoms. CRPS can also result from otherwise successful surgeries, drug exposure, strokes involving partial brain paralysis, and cervical spondylosis.
Xii See Harris v. Seaboard Farms of Elberton, 207 Ga. App. 147 (Ga. Ct. App. 1993).
xiii Old Dominion Freight Line v. Anthony, 216 Ga. App. 267 (Ga. Ct. App. 1995).
ixx See Sidney Coal Co. v. Huffman. 233 S. W.3d 710(Ky. 2007).
xx The final PPD award was returned for recalculation.
xxi See Lejeune v. Transocean Offshore Deepwater Drilling Inc., U.S. App. (2007).
xxii Although the Superior Court’s award for general damages was later reduced when the case was remanded to the trial judge for recalculation fo future medicals and lost wages, the final award remained substantially intact.
xxiii Golla v General Motors Corp 261 III. App. 143, 198 (1994). Here, the plantiff voluntarily and promptly received medical treatment for her injuries from the precipitating accident, an auto collision, so the argument that she knew that she was injured in some way due to the negligent conduct of the tortfeasor immediately after the collision carried more weight than her contention that the statute began running against the negligent party years later when she was first diagnosed with RSD.