Under Iowa law, employees who develop complex regional pain syndrome from a work injury are entitled to receive loss of earning capacity damages.

The Iowa Workers’ Compensation Commissioner entered an Appeal Decision on December 13, 2019, in the case of Griselda Perez-Avina v. Brenneman Pork, Inc. and Farm Bureau Property & Casualty Company that is a good example of how complex regional pain syndrome cases are analyzed.

Ms. Perez-Avina worked as a laborer in the farrowing department of Brenneman Pork.  She injured her right hand on February 26, 2014, while assisting a sow that was giving birth.

A few weeks later, on April 16, 2014, she tripped and fell while working with the sows and injured her left arm and her left leg.

Neither of the incidents were particularly serious, but the Claimant had a lot of problems in treatment.

On May 9, 2014, Perez-Avina attended an appointment with James Milani, D.O.  Ultimately, Dr. Milani assessed Perez-Avina with a right-hand injury, found she was at maximum medical improvement, released her to return to work without restrictions, and opined Perez-Avina’s continued and worsening symptoms were not related to the February 2014 work injury.

On May 20, 2014, Dr. Milani observed “bruising, erythema, edema, or warmth” in the left upper extremity, and he assessed her with “status post fall at work” on April 16, 2014.  Dr. Milani then opined while Perez-Avina needed additional medical evaluation and treatment, but her symptoms were out of proportion, inconsistent with, and unrelated to the April 14 work injury.

On May 30, 2014, Perez-Avina told Dr. Robinson she felt she was not getting better.  Dr. Robinson increased her gabapentin dose, refilled her Vicodin, and recommended a referral to an orthopaedic surgeon, possible trigger point injections, and physical therapy.

On September 2, 2014, was examined by Curtis Frier, D.O., a family medicine physician, complaining of bilateral arm, back, and neck pain that was radiating down her arm to her fingertips with “shakiness” and facial pain on the left side.

During a follow-up appointment with Dr. Frier on September 28, 2014, Perez-Avina complained of bilateral arm, neck and shoulder pain, with limited range of motion in her bilateral arms, and reported her shoulder and elbow were popping.  Dr. Frier recommended therapy and noted “all issues stem from her work related injury in my opinion.  I believe she has progressed to reflex somatic dystrophy.”  He diagnosed her with neck pain, radicular syndrome of the arms, and reflex sympathetic dystrophy.

On October 26, 2014, Perez-Avina returned to Dr. Frier, reporting pain was better, but complaining of left side lower back pain, radiating into her left leg that comes and goes.  Dr. Frier assessed her with neck pain and reflex sympathetic dystrophy.  She received a shoulder injection and pharmacological treatment.

On November 26, 2014, Frederick Dery, M.D. examined Perez-Avina and noted she did not have any swelling, color changes, skin, nail or hair changes on her forearms and hands, normal skin temperature, and she had “patchy allodynia to light touch left greater than right.”  She reported an intense cold sensation in her hands and forearms.  She had a tremor that “is much more marked in the fingers bilaterally than in the upper arms bilaterally.  This is much worse with intention of grasp bilaterally.  Her grip is weaker than what I would expect for a 31-year-old female.”  Diagnosed with pain in the joint of her forearm, pain in the joint of her hand, numbness and tingling, and complex regional pain syndrome type I.  Discontinued prescription for gabapentin, prescribed Lyrica, Norvasc and physical therapy, imposed a ten-pound weightlifting restriction with occasional lifting and encouraged Perez-Avina to use both of her upper extremities as much as possible.

On February 15, 2015, Perez-Avina had a follow up appointment with Dr. Frier reporting her symptoms were interfering with her activities of daily living, sleep, work, and household activities.  Dr. Frier diagnosed Perez-Avina with neck pain, radicular syndrome of the arms, reflex sympathetic dystrophy, and depression, and prescribed Symbalta and tramadol.

During an appointment on March 4, 2015, Dr. Dery noted Perez-Avina “has pain and symptoms that do not meet classic CRPS type I but she has many of those criteria based on history,” with her arm being primarily affected.  Dr. Dery reduced her Lyrica, prescribed propranolol, continued her Norvasc, and prescribed physical therapy.

She continued to complain of pain and reported pain traveling down her hip and leg.  During her March 11, 2015, appointment, she reported she was experiencing color changes and swelling in her arm and hand.  Dr. Dery observed “a little bit of swelling in her hand and fingers on the left,” but he did not document any abnormal temperature sensation or color changes.  Dr. Dery listed an impression of “CRPS type I affecting the left upper extremity,” which is a work-related injury, and recommended a referral to John Dooley, M.D., an anesthesiologist specializing in pain management.

On May 11, 2015, Alicia Liebe, PT, issued a letter stating she had treated Perez-Avina since September 23, 2014, for a total of 97 visits.  Liebe noted Perez-Avina had excellent compliance at therapy and at home and gave “100% of her effort every visit.”

On June 4, 2015, Perez-Avina attended an appointment to establish care with Dr. Dooley at Pain Centers of Iowa.  Dr. Dooley’s staff documented she had excessive sweating and diaphoresis of the skin, but no rashes, swelling, or redness.

On June 12, 2015, Perez-Avina saw Dr. Dooley complaining of arm pain.  Dr. Dooley documented “[o]verall examination of patient’s skin reveals – no suspicious lesions.”  Color and skin moisture is normal.  “Upper extremity: inspection – bilateral – pink nail beds, pink skin and rapid capillary refill.  No loss of hair, shiny atrophic skin or thick rigid nails.  Not acrocyanotic, blanched or pale.”  Lower extremity inspection bilateral normal.  Dr. Dooley assessed her with chronic pain due to trauma, opined she is not a candidate for “”ITD or SCS,” recommended she be weaned from opioids, and recommended an evaluation for psychiatric origins of her discomfort.

On August 6, 2015, she saw Dr. Frier complaining of pain in the entire left side of her body and her right wrist, neck, and shoulder, and bumps from sweating.  Dr. Frier diagnosed Perez-Avina with complex regional pain syndrome and folliculitis.

Dr. Frier wrote an opinion letter in September 2015, agreeing with Dr. Dery’s diagnosis “that her symptoms are most consistent [with] CRPS and I feel she does meet criteria for CRPS,” caused by her work injuries on February 26, 2014 and April 16, 2014.  Dr. Frier opined, “I do not believe Griselda can return to work at this time due to her pain & motion limitations.”

Joseph Chen, M.D. conducted an IME for Brenneman Port and Farm Bureau on November 30, 2015.  Dr. Chen opined Perez-Avina “does not have complex regional pain syndrome and that a pain pump would NOT be effective treatment for her condition.”  Dr. Chen noted he was uncertain why Perez-Avina has developed chronic pain, but he “could not attribute this to either of her work incidents.”

Dr. Chen found Perez-Avina reached Maximum Medical Improvement as of November 30, 2015, and that he was “unable to substantiate a medical etiology for her chronic pain to have occurred as a result of any injury.”  Using the Guides to the Evaluation of Permanent Impairment, 5th Ed., Dr. Chen opined Perez-Avina has no ratable permanent impairment rating and has no need for future medical treatment.

On December 4, 2015, she was seen by Dr. Frier, she reported her pain was worsening and she was unable to bear weight.  Dr. Frier diagnosed her with depression and complex regional pain syndrome, and prescribed Symbalta, amlodipine besylate, and propranolol.

On January 11, 2016, she attended an appointment with Maruti Kari, M.D., an anesthesiologist specializing in pain management.  Dr. Kari noted she has been using a wheelchair for two weeks, she had significant tremors with extension of her elbows, she refused to abduct her shoulders secondary to pain, and she had “severe allodynia all over the back, left upper extremity, right upper extremity, left lower extremity, and lower back.”  Dr. Kari documented no skin color changes, hair color changes, nail changes and “no significant changes in temperature, left compared to right.”

Dr. Kari assessed her with complex regional pain syndrome type I of the bilateral upper extremities and left lower extremity versus generalized neuropathic pain syndrome.

On February 16, 2015, Perez-Alvina received lumbar spine magnetic resonance imaging.  The reviewing radiologist noted an impression of central L4-5 disc protrusion with mild narrowing of the spinal cord.

On March 2, 2016, counsel for Perez-Avina sent a letter to Dr. Kari, attaching medical records and requesting his opinions.  Counsel asked whether Perez-Avina’s diagnosis is “Complex Regional Pain Syndrome type 1 of the bilateral upper extremities and left lower extremities vs. generalized neuropathic pain syndrome.”  Dr. Kari responded “yes I agree with that statement.  She does not meet all the criteria for CRPS Type I, but CRPS also has a spectrum of presentation and not all symptoms and signs exist at all times.”  Dr. Kari opined he believed her condition is related to her work injuries.

On March 16, 2016, Dr. Frier assessed Perez-Avina with neck pain, back pain, lumbago with sciatica on the left side, complex regional pain syndrome, and herniated lumbar disc.

On May 2, 2016, Perez-Alvina saw Dr. Frier.  She had limited range of motion in her right shoulder and elbow with pain, and she was unable to fully extend her left knee.  Dr. Frier assessed Perez-Avina with complex regional pain syndrome, cervicalgia, dorsalgia, and major depressive disorder, and continued her prescriptions.

On May 11, 2016, after being admitted to the hospital for placement of an intrathecal pump trial Dr. Kari indicated he believed Perez-Avina had developed complex regional pain syndrome type 1 of the bilateral upper extremities after two work injuries and opined her lower extremity weakness does not meet the diagnostic criteria of complex regional pain syndrome.  Dr. Kari noted during the trial Perez-Avina experienced significant pain relief and improved ability to walk using a walker, less tremors in her upper extremity, and less allodynia in response to the dilaudid and clonidine, and recommended permanent placement of the pump.

On July 1, 2016, Dr. Kari placed a permanent intrathecal pump in Perez-Avina.  During a recheck on July 8, 2016, Dr. Kari noted Perez-Avina’s family reported she was using a wheelchair, she was unable to walk, and she was unable to feed herself.  She reported since the procedure she was experiencing less pain.  He diagnosed Perez-Alvina with complex regional pain syndrome type 1 of both upper extremities.

During an appointment with Dr. Frier on July 27, 2016, Perez-Avina complained of left ankle and foot swelling.  Dr. Frier assessed her with left leg swelling, left leg pain, complex regional pain syndrome I of other specified site, and major depressive disorder and he prescribed Furosemide for the swelling.  Dr. Frier later prescribed a walker.

The Claimant hired a lawyer and filed a workers’ compensation case.  The Claimant’s lawyer had her seen for an independent medical examination, and her IME doctor diagnosed her with complex regional pain syndrome in the bilateral arms and the left leg.

The Defendants requested opinions from several doctors who concluded that the Claimant did not have complex regional pain syndrome.

Both the Deputy Commissioner who presided over the trial in the case, and the Commissioner who ruled on the appeal found that the Claimant was severely disabled.  The Deputy’s analysis of the damages was:

In considering the credibility of the three testifying witnesses, the Deputy finds the testimony of Perez-Avina, her husband, and her physical therapist, Turner, credible and supportive that she is permanently and totally disabled.

The record supports Perez-Avina has shown motivation to improve her functioning by attending more than 360 physical therapy sessions since her work injuries.  In her video she produced, she is struggling to grip a round dowel with her right hand.

During Perez-Avina’s testimony she appeared fatigued, and her grimaces and gestures were consistent with a person experiencing physical discomfort and pain.  Based on the Deputy’s observations, he found all three witnesses credible.

Brenneman Pork terminated Perez-Avina’s employment on June 2, 2014, after receiving her work restrictions from Dr. Robinson, finding it could not reasonably accommodate her.  Since her second work injury, Perez-Avina has been unable to return to any work.  Her records document she is unable to feed herself, and she and her husband testified about her difficulties in self-care.

At hearing, she was age 34.  She dropped out of school in Mexico after middle school, but later earned a general education diploma after moving to the United States.  Her primary language is Spanish, and she describes her English abilities as “very limited.”  Given her limited education, work experience, and difficulty using her bilateral arms for basic self-care, I find her prospects for retraining limited.  Perez-Avina suffers from chronic pain that limits her ability to work.

Based on the factors for evaluating industrial disability, I conclude Perez-Avina has met her burden of proof that she has sustained a 100% percent loss of earning capacity as a result of her work injuries.

Accordingly, the Deputy and the Commissioner found that the Claimant was permanently and totally disabled from her complex regional pain syndrome and the Defendants were required to pay weekly benefits at the Claimant’s workers’ compensation rate for the rest of her life, and provide medical care for her complex regional pain syndrome.