I. MEDICAL BACKGROUND OF COMPLEX REGIONAL PAIN SYNDROME
The cause of Complex Regional Pain Syndrome (CRPS) is not well understood. The current theories are that CRPS is caused by an injury or an abnormality of the peripheral and central nervous systems. CRPS generally occurs as the result of a physical injury or trauma such as infections, surgery and heart attacks.
There are two main types of CRPS. Type 1 is also known as Reflex Sympathetic Dystrophy Syndrome (RSD). Type 1 CRPS develops after an injury or illness that does not directly damage the nerves in the affected limb.
Type 2 is also sometimes referred to as Causalgia. Type 2 and Type 1 CRPS have similar symptoms. The difference is that Type 2 CRPS follows a definite nerve injury.
The symptoms of CRPS can include:
- Decreased ability to move the affected body part.
- Weakness and muscle loss.
- Stiff joints and swelling and damage to the joints.
- Changes in hair and nail growth.
- Changes in skin texture.
- Changes in skin color.
- Changes in skin temperature.
- Swelling of the painful area.
- Sensitivity to touch.
- Sensitivity to cold.
- Burning or throbbing pain.
Early treatment of CRPS is generally the most successful.
Medical providers use a wide range of medications to help treat CRPS, including: pain relievers, anti-depressants, anti-convulsants, corticoid steroids, bone loss prevention medications, and injections of nerve blocking medication. A variety of therapies can also help, including heat therapy, topical analgesics, physical therapy, TENS Units and biofeedback. In some cases spinal cord stimulation is also used.
Living with a chronic pain condition such as CRPS is very challenging. Continuing as many of your regular activities as possible is generally helpful. Therapy with a professional or a support group is also a good approach for many people.
II. COMPLEX REGIONAL PAIN SYNDROME IS AN INDUSTRIAL DISABILITY INJURY UNDER IOWA WORKERS’ COMPENSATION LAW
CRPS is frequently present in an injured worker’s hands, arms, or legs. Generally, injuries to the hands, arms, or legs are treated as scheduled injuries with a specific limitation of how many weeks of permanent partial disability benefits a worker may recover.
However, an injury to a scheduled body part which includes CRPS is treated as an industrial disability injury. Therefore, the potential recovery for the injured worker is larger.
III. LUSCOMBE v. IDA COUNTY SHERIFF’S DEPT. AND IOWA MUNICIPALITIES WORKERS’ COMPENSATION ASSOCIATION
On March 7, 2018 the Iowa Workers’ Compensation Commissioner issued an Appeal Decision in the case of Luscombe v. IDA County Sheriff’s Dept. and Iowa Municipalities Workers’ Compensation Association which is a good example of how a CRPS case is analyzed under Iowa law.
The Claimant was a 44 year old high school graduate. The Claimant was hired by IDA County in June of 2006 as a 9-1-1 operator and as a jailor. The Claimant’s normal shift was from 6:00 p.m. to 6:00 a.m.
On October 23, 2012 the Claimant was cleaning a jail cell when she struck her right hand above her little ring finger on a metal table attached to the wall. She reported the injury immediately. The injury was also recorded on a security video.
The emergency room assessment was that the Claimant had a bruise, pain and swelling to the back of her right hand. X-rays were negative for any fractures. The Claimant was advised to ice her hand and take anti-inflammatories for her injury.
Unfortunately, the Claimant’s hand injury did not resolve. The symptoms actually worsened and spread. The Claimant developed severe burning pain in her hand and arm that limited her ability to use her hand.
The Claimant was evaluated and treated by a large number of medical care providers.
By July of 2013 one of the doctors gave the opinion that he had no other treatment to offer and he did not see clinical signs of CRPS. Based on this opinion the Defendants took the position that the Claimant’s continuing hand problems were not related to the work incident and closed the case.
After this denial the Claimant moved forward to obtain medical care on her own and at the time of the workers’ compensation trial was being seen by John Cook, M.D. who is a specialist in pain management.
The Claimant was in pain, but continued to perform her regular duties without restrictions.
In the Commissioner’s Appeal Decision he adopted and affirmed the findings and analysis of the Deputy Workers’ Compensation Commissioner who had presided over the original trial of the case. The Deputy Commissioner’s Decision had noted:
“The defendants provided a formidable defense. The diagnosis of CRPS is a complicated diagnosis and the defendants have solid treating experts, including most notably, Dr. Benedetti, who does not believe it is the correct diagnosis. The problem is that the evidence is quite convincing to me that there is something wrong with Ms. Luscombe’s right hand and arm. The defendants have not provided me with an alternative of what the problem is. It seems that as soon as the physicians decided that the correct diagnosis was not RSD/CRPS, there was no further attempt to diagnose the correct condition. The defendants simply denied the claim and moved on. It is unclear, for example, what Dr. Benedetti deemed the problem to be. Dr. Wampler stated that claimant ‘has a subjective pain syndrome that cannot be defined medically and should not warrant any additional treatment, investigation or restriction.’ (Def. Ex. L, p. 6) When read in conjunction with the remainder of his report, he seems to be suggesting that the pain is either in her head, not real, or somehow entirely unrelated to her work injury. I do not find that the greater weight of evidence supports such a conclusion.
It is, of course, the claimant’s burden to not only prove that the work injury has caused a medical condition and impairment, but also what that diagnosis is. There is no burden upon the defendants. The diagnosis of chronic pain was originally used by Dr. Hsu in January 2013. Dr. Johnson then used the diagnosis of RSD in February 2013. Dr. Hsu and Dr. Johnson both felt comfortable using the working diagnosis of RSD or CRPS initially. It was not until after the nurse case manager became involved and it was evident the precise diagnosis was crucial, that the diagnosis was really questioned. For example, Dr. Hsu provided a huge impairment rating on the basis of RSD, which he withdrew a few weeks later after meeting with the nurse case manager. (Cl. Ex. 6, pp. 8-10) Dr. Johnson continued to use RSD as a working diagnosis in his treatment. (Cl. Ex. 9, p. 17) While Dr. Benedetti specifically ruled out the diagnosis of CRPS/RSD, she stated that further ‘investigation will be required to delineate the source of her pain.’ (Cl. Ex. 10, p. 3) Moreover, the treatment recommended by Dr. Benedetti was never authorized. The lack of a plausible alternative diagnosis, to some degree, hurts the defense.”
The Workers’ Compensation Commissioner noted that three different doctors had all felt confident treating the Claimant using the diagnosis of CRPS. These were all treating physicians who were merely attempting to help the Claimant to prove her medical condition.
The Deputy Commissioner also noted that the Claimant had a strong expert opinion pursuant to her independent medical examination.
Both the Deputy Commissioner and the Commissioner found that the Claimant suffered from CRPS and that the CRPS was substantially caused, aggravated or lit up by her work injury. The Commissioner ordered that the Defendants pay the Claimant 100 weeks of permanent partial disability benefits.
The Defendants were also ordered to pay for all of the Claimant’s medical expenses after the Defendants closed the case, and all of the time that the Claimant missed work for attending these medical appointments.
The Defendants were also ordered to authorize and pay for the ongoing care of the Claimant by Dr. Cook.
Please be sure to contact us if you have any questions about CRPS, or any other Iowa workers’ compensation issues.