SSR 03-02p: SSR 03-2p: Titles II and XVI: Evaluating Cases Involving Reflex Sympathetic Dystrophy Syndrome/Complex Regional Pain Syndrome

[Federal Register: October 20, 2003 (Volume 68, Number 202)/Notices] [Page 59971-59976]

EFFECTIVE DATE: October 20, 2003

Policy Interpretation Ruling

Purpose:

To explain the policies of the Social Security

Administration for developing and evaluating title II and title XVI

claims for disability on the basis of Reflex Sympathetic Dystrophy

Syndrome (RSDS), also frequently known as Complex Regional Pain

Syndrome, Type I (CRPS). These terms are synonymous and are used to

describe a unique clinical syndrome that may develop following trauma.

This syndrome is characterized by complaints of intense pain and

typically includes signs of autonomic dysfunction.

Citations (Authority):

Sections 216(i) , 223(d) , 1614(a)(3) , 1614(a)(4) and 1614(c) of the Social Security Act (the Act), as

amended; Regulations No. 4, subpart P, sections 404.1502 , 404.1505 , 404.1508 - 404.1509 , 404.1511 - 404.1513 , 404.1520 , 404.1520a , 404.1521 , 404.1523 , 404.1526 - 404.1530 , 404.1545 - 404.1546 , 404.1560 - 404.1569a ; and 404.1593 - 404.1594 and

appendix 1; and Regulations No. 16, subpart I,

sections 416.902 , 416.905 , 416.906 , 416.908 - 416.909 , 416.911 - 416.913 , 416.920 , 416.920a , 416.921 , 416.923 , 416.924 , 416.924a -416.924c, 416.925 , 416.926 , 416.926a , 416.927 - 416.930 , 416.945 - 416.946 , 416.960 - 416.969a , 416.987 , and 416.993 - 416.994a .

Introduction:

RSDS/CRPS are terms used to describe a constellation

of symptoms and signs that may occur following an injury to bone or

soft tissue. The precipitating injury may be so minor that the

individual does not even recall sustaining an injury. Other potential

precipitants suggested by the medical literature include, but are not

limited to, surgical procedures, drug exposure, stroke with hemiplegia,

and cervical spondylosis.

Policy Interpretation

What Is RSDS/CRPS?

that may occur following an injury to bone or

soft tissue. The precipitating injury may be so minor that the

individual does not even recall sustaining an injury. Other potential

precipitants suggested by the medical literature include, but are not

limited to, surgical procedures, drug exposure, stroke with hemiplegia,

and cervical spondylosis.

Policy Interpretation

What Is RSDS/CRPS?

RSDS/CRPS is a chronic pain syndrome most often resulting from

trauma to a single extremity. It can also result from diseases,

surgery, or injury affecting other parts of the body. Even a minor

injury can trigger RSDS/CRPS. The most common acute clinical

manifestations include complaints of intense pain and findings

indicative of autonomic dysfunction at the site of the precipitating

trauma. Later, spontaneously occurring pain may be associated with

abnormalities in the affected region involving the skin, subcutaneous

tissue, and bone. It is characteristic of this syndrome that the degree

of pain reported is out of proportion to the severity of the injury

sustained by the individual. When left untreated, the signs and

symptoms of the disorder may worsen over time.

Although the pathogenesis of this disorder (the precipitating

mechanism(s) of the signs and symptoms characteristic of RSDS/CRPS) has

not been defined, dysfunction of the sympathetic nervous system has

been strongly implicated.

The sympathetic nervous system regulates the body's involuntary

physiological responses to stressful stimuli. Sympathetic stimulation

results in physiological changes that prepare the body to respond to a

stressful stimulus by “fight or flight.” The so-called “fight or

flight” response is characterized by constriction of peripheral

vasculature (blood vessels supplying skin), increase in heart rate and

sweating, dilatation of bronchial tubes, dilatation of pupils, increase

in level of alertness, and constriction of sphincter musculature.

ogical changes that prepare the body to respond to a

stressful stimulus by “fight or flight.” The so-called “fight or

flight” response is characterized by constriction of peripheral

vasculature (blood vessels supplying skin), increase in heart rate and

sweating, dilatation of bronchial tubes, dilatation of pupils, increase

in level of alertness, and constriction of sphincter musculature.

Abnormal sympathetic nervous system function may produce

inappropriate or exaggerated neural signals that may be misinterpreted

as pain. In addition, abnormal sympathetic stimulation may produce

changes in blood vessels, skin, musculature and bone. Early recognition

of the syndrome and prompt treatment, ideally within 3 months of the

first symptoms, provides the greatest opportunity for effective

recovery.

How Does RSDS/CRPS Typically Present?

RSDS/CRPS patients typically report persistent, burning, aching or

searing pain that is initially localized to the site of the injury. The

involved area usually has increased sensitivity to touch. The degree of

reported pain is often out of proportion to the severity of the

precipitating injury. Without appropriate treatment, the pain and

associated atrophic skin and bone changes may spread to involve an

entire limb. Cases have been reported to progress and spread to other

limbs, or to remote parts of the body.

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 of

RSDS/CRPS persist longer than 6 months in 50 percent of cases, and may

last for years in cases where treatment is not successful.

What Are the Diagnostic Criteria for RSDS/CRPS?

A diagnosis of RSDS/CRPS requires the presence of complaints of

persistent, intense pain that results in impaired mobility of the

affected region. The complaints of pain are associated with:

signs and symptoms of

RSDS/CRPS persist longer than 6 months in 50 percent of cases, and may

last for years in cases where treatment is not successful.

What Are the Diagnostic Criteria for RSDS/CRPS?

A diagnosis of RSDS/CRPS requires the presence of complaints of

persistent, intense pain that results in impaired mobility of the

affected region. The complaints of pain are associated with:

- Swelling;

- Autonomic instability—seen as changes in skin color or

texture, changes in sweating (decreased or excessive sweating), skin

temperature changes, or abnormal pilomotor erection (gooseflesh);

- Abnormal hair or nail growth (growth can be either too slow

or too fast);

- Osteoporosis; or

- Involuntary movements of the affected region of the initial

injury.

Swelling;

Autonomic instability—seen as changes in skin color or

texture, changes in sweating (decreased or excessive sweating), skin

temperature changes, or abnormal pilomotor erection (gooseflesh);

Abnormal hair or nail growth (growth can be either too slow

or too fast);

Osteoporosis; or

Involuntary movements of the affected region of the initial

injury.

Progression of the clinical disorder is marked by worsening of a

previously identified finding, or the manifestation of additional

abnormal changes in the skin, nails, muscles, joints, ligaments, and

bones of the affected region. Clinical progression does not necessarily

correlate with specific timeframes. Efficacy of treatment must be

judged on the basis of the treatment's effect on the pain and whether

or not progressive changes continue in the tissues of the affected

region.

, or the manifestation of additional

abnormal changes in the skin, nails, muscles, joints, ligaments, and

bones of the affected region. Clinical progression does not necessarily

correlate with specific timeframes. Efficacy of treatment must be

judged on the basis of the treatment's effect on the pain and whether

or not progressive changes continue in the tissues of the affected

region.

Reported pain at the site of the injury may be followed by

complaints of muscle pain, joint stiffness, restricted mobility, or

abnormal hair and nail growth in the affected region. Further, signs of

autonomic instability (changes in the color or temperature of the skin

and frequent appearance of goose bumps) may develop in the affected

region. Osteoporosis may be noted by appropriate medically acceptable

imaging techniques. Complaints of pain can further intensify, and can

be reported to spread to involve other extremities. Muscle atrophy and

contractures can also develop. Persistent clinical progression

resulting in muscle atrophy and contractures, or progression of

complaints of pain to include other extremities or regions, in spite of

appropriate diagnosis and treatment, hallmark a poor prognosis.

How Is RSDS/CRPS Treated?

Patient education and activity programs designed to increase limb

mobility and promote use of the extremity or affected region during

activities of daily living are considered the most important treatments

for RSDS/CRPS. The medical literature has demonstrated that individuals

affected by RSDS/CRPS have a better prognosis when they receive an

early diagnosis and mobility is immediately encouraged. In some

patients, it is necessary to inject a long-acting anesthetic to block

sympathetic activity and reduce pain to allow the individual to

increase the mobility of the affected region. Various analgesics,

including narcotics and neurostimulators, may be used to minimize pain

and promote the individual's ability to tolerate greater mobility.

osis and mobility is immediately encouraged. In some

patients, it is necessary to inject a long-acting anesthetic to block

sympathetic activity and reduce pain to allow the individual to

increase the mobility of the affected region. Various analgesics,

including narcotics and neurostimulators, may be used to minimize pain

and promote the individual's ability to tolerate greater mobility.

A mental evaluation may be requested by treating or other medical

sources to determine if any undiagnosed psychiatric disease is present

that could potentially contribute to a reduced pain tolerance. It is

important to recognize that such evaluations are not based on concern

that RSDS/CRPS findings are imaginary or etiologically linked to

psychiatric disease. The behavioral and cognitive effects of the

medications used to treat pain need to be thoroughly considered in the

evaluation of this syndrome.

Other types of medications may also be used to reduce pain. Anti-

inflammatory preparations, psychotropic medications (for example,

antidepressants), certain antiepileptic drugs, muscle relaxants, and

drugs that produce generalized reduction in sympathetic outflow may be

tried in an effort to reduce the signs and symptoms associated with

RSDS/CRPS and improve the mobility of the affected region.

Patients who are noted to have a good response to local sympathetic

blocks may be considered candidates for surgical sympathectomy. This

procedure permanently disrupts the sympathetic innervation of the

affected region. It involves destroying a sympathetic ganglion and must

be performed by a physician who is an expert in this technique. This

procedure is not without risk of post-surgical complications.

What Is a Medically Determinable Impairment?

thetic

blocks may be considered candidates for surgical sympathectomy. This

procedure permanently disrupts the sympathetic innervation of the

affected region. It involves destroying a sympathetic ganglion and must

be performed by a physician who is an expert in this technique. This

procedure is not without risk of post-surgical complications.

What Is a Medically Determinable Impairment?

Sections 216(i) and 1614(a)(3) of the Act define

“disability” [1] as the inability to engage in any substantial gainful activity by

reason of any medically determinable physical or mental impairment (or

combination of impairments) which can be expected to result in death or

which has lasted or can be expected to last for a continuous period of

not less than 12 months. [2]

Sections 223(d)(3) and 1614(a)(3)(D) of the

Act, and 20 CFR 404.1508 and 416.908 ,

require that impairment result from anatomical,

physiological, or psychological abnormalities that can be shown by

medically acceptable clinical and laboratory diagnostic techniques. The

Act and regulations further require that impairment be established by

medical evidence that consists of signs, symptoms, and laboratory

findings, and not only by an individual's statement of symptoms.

How Is RSDS/CRPS Identified as a Medically Determinable Impairment?

RSDS/CRPS constitutes a medically determinable impairment when it

is documented by appropriate medical signs, symptoms, and laboratory

findings, as discussed above. RSDS/CRPS may be the basis for a finding

of “disability.” Disability may not be established on the basis of an

individual's statement of symptoms alone.

For purposes of Social Security disability evaluation, RSDS/CRPS

can be established in the presence of persistent complaints of pain

that are typically out of proportion to the severity of any documented

precipitant and one or more of the following clinically documented

signs in the affected region at any time following the documented

precipitant:

- Swelling;

atement of symptoms alone.

For purposes of Social Security disability evaluation, RSDS/CRPS

can be established in the presence of persistent complaints of pain

that are typically out of proportion to the severity of any documented

precipitant and one or more of the following clinically documented

signs in the affected region at any time following the documented

precipitant:

- Swelling;

- Autonomic instability—seen as changes in skin color or

texture, changes in sweating (decreased or excessive sweating), changes

in skin temperature, and abnormal pilomotor erection (gooseflesh);

- Abnormal hair or nail growth (growth can be either too slow

or too fast);

- Osteoporosis; or

- Involuntary movements of the affected region of the initial

injury.

Swelling;

Autonomic instability—seen as changes in skin color or

texture, changes in sweating (decreased or excessive sweating), changes

in skin temperature, and abnormal pilomotor erection (gooseflesh);

Abnormal hair or nail growth (growth can be either too slow

or too fast);

Osteoporosis; or

Involuntary movements of the affected region of the initial

injury.

When longitudinal treatment records document persistent limiting

pain in an area where one or more of these abnormal signs has been

documented at

some point in time since the date of the precipitating injury,

disability adjudicators can reliably determine that RSDS/CRPS is

present and constitutes a medically determinable impairment. It may be

noted in the treatment records that these signs are not present

continuously, or the signs may be present at one examination and not

appear at another. Transient findings are characteristic of RSDS/CRPS,

and do not affect a finding that a medically determinable impairment is

present.

How Is Medical Evidence of the Impairment Documented?

tes a medically determinable impairment. It may be

noted in the treatment records that these signs are not present

continuously, or the signs may be present at one examination and not

appear at another. Transient findings are characteristic of RSDS/CRPS,

and do not affect a finding that a medically determinable impairment is

present.

How Is Medical Evidence of the Impairment Documented?

In cases involving RSDS/CRPS, the documentation of medical signs or

laboratory findings at some point in time in the clinical record since

the date of the precipitating injury is critical in establishing the

presence of a medically determinable impairment. In cases in which

RSDS/CRPS is alleged, longitudinal clinical records reflecting ongoing

medical evaluation and treatment from the individual's medical sources,

especially treating sources, are extremely helpful in documenting the

presence of any medical signs, symptoms and laboratory findings.

Generally, evidence for the 12-month period preceding the month of

application should be obtained, unless there is reason to believe that

development of an earlier period is necessary, the alleged onset of

disability is less than 12 months before the date of the application,

or a fully favorable determination can be made with less evidence.

If the adjudicator finds that the evidence is inadequate to

determine whether the individual is disabled, he or she must first

recontact the individual's treating or other medical source(s) to

determine whether the additional information needed is readily

available, in accordance with 20 CFR 404.1512 and 416.912 . Only after

the adjudicator determines that the information is not readily

available from the individual's health care provider(s), or that the

necessary information or clarification cannot be sought from the

individual's health care provider(s), should the adjudicator proceed to

arrange for a consultative examination(s) in accordance with 20 CFR 404.1519a and 416.919a

1512 and 416.912 . Only after

the adjudicator determines that the information is not readily

available from the individual's health care provider(s), or that the

necessary information or clarification cannot be sought from the

individual's health care provider(s), should the adjudicator proceed to

arrange for a consultative examination(s) in accordance with 20 CFR 404.1519a and 416.919a .

The type of consultative examination(s)

purchased will depend on the nature of the individual's symptoms and

the extent of the evidence already in the case record.

It should be noted that conflicting evidence in the medical record

is not unusual in cases of RSDS due to the transitory nature of its

objective findings and the complicated diagnostic process involved.

Clarification of any such conflicts in the medical evidence should be

sought first from the individual's treating or other medical sources.

Medical opinions from treating sources about the nature and

severity of an individual's impairment(s) are entitled to deference and

may be entitled to controlling weight. If we find that a treating

source's medical opinion on the issue of the nature and severity of an

individual's impairment(s) is well-supported by medically acceptable

clinical and laboratory diagnostic techniques and is not inconsistent

with the other substantial evidence in the case record, the adjudicator

will give it controlling weight.

(See SSR 96-2p , “Titles II and XVI:

Giving Controlling Weight to Treating Source Medical Opinions,” and SSR 96-5p , “Titles II and XVI:

Medical Source Opinions on Issues Reserved to the

Commissioner.”) [3]

How Is the Duration and Severity of RSDS/CRPS Established?

not inconsistent

with the other substantial evidence in the case record, the adjudicator

will give it controlling weight.

(See SSR 96-2p , “Titles II and XVI:

Giving Controlling Weight to Treating Source Medical Opinions,” and SSR 96-5p , “Titles II and XVI:

Medical Source Opinions on Issues Reserved to the

Commissioner.”) [3]

How Is the Duration and Severity of RSDS/CRPS Established?

The signs and symptoms of RSDS/CRPS may remain stable over time,

improve, or worsen. Documentation should, whenever appropriate, include

a longitudinal clinical record containing detailed medical

observations, treatment, the individual's response to treatment,

complications of treatment, and a detailed description of how the

impairment limits the individual's ability to function and perform or

sustain work activity over time.

Chronic pain and many of the medications prescribed to treat it may

affect an individual's ability to maintain attention and concentration,

as well as adversely affect his or her cognition, mood, and behavior,

and may even reduce motor reaction times. These factors can interfere

with an individual's ability to sustain work activity over time, or

preclude sustained work activity altogether. When evaluating duration

and severity, as well as when evaluating RFC, the effects of chronic

pain and the use of pain medications must be carefully considered.

When the alleged onset of disability secondary to RSDS/CRPS

occurred less than 12 months before adjudication, the adjudicator must

evaluate the available medical evidence and project the degree of

impairment severity that is likely to exist at the end of 12 months.

Information about treatment and response to treatment, as well as any

medical source opinions about the individual's prognosis at the end of

12 months, are helpful in deciding whether the medically determinable

impairment is expected to be of disabling severity for at least 12

consecutive months.

project the degree of

impairment severity that is likely to exist at the end of 12 months.

Information about treatment and response to treatment, as well as any

medical source opinions about the individual's prognosis at the end of

12 months, are helpful in deciding whether the medically determinable

impairment is expected to be of disabling severity for at least 12

consecutive months.

In those cases in which an individual is found disabled based on

RSDS/CRPS, but medical improvement is anticipated, the adjudicator

should schedule an appropriate medical reexamination date consistent

with the information indicating the likelihood of medical improvement.

How Is RSDS/CRPS Evaluated?

Claims in which the individual alleges RSDS/CRPS are adjudicated

using the sequential evaluation process, just as for any other

impairment. Because finding that RSDS/CRPS is a medically determinable

impairment requires the presence of chronic pain and one or more

clinically documented signs in the affected region, the adjudicator can

reliably find that pain is an expected symptom in this disorder. Other

symptoms, including such things as extreme sensitivity to touch or

pressure, or abnormal sensations of heat or cold, can also be

associated with this disorder. Given that a variety of symptoms can be

associated with RSDS/CRPS, once the disorder has been established as a

medically determinable impairment, the adjudicator must evaluate the

intensity, persistence, and limiting effects of the individual's

symptoms to determine the extent to which the symptoms limit the

individual's ability to do basic work activities. For this purpose,

whenever the individual's statements about the intensity, persistence,

or functionally limiting effects of pain or other symptoms are not

substantiated by objective medical evidence, the adjudicator must make

a finding on the credibility of the individual's statements based on a

consideration of the entire case record

individual's ability to do basic work activities. For this purpose,

whenever the individual's statements about the intensity, persistence,

or functionally limiting effects of pain or other symptoms are not

substantiated by objective medical evidence, the adjudicator must make

a finding on the credibility of the individual's statements based on a

consideration of the entire case record. This includes the medical

signs and laboratory findings, the individual's own statements about

the symptoms, any statements and other information provided by treating

or examining physicians or psychologists and other persons about the

symptoms and how they affect the individual, and any other relevant

evidence in the case record. Although symptoms alone

cannot be the basis for finding a medically determinable impairment,

once the existence of a medically determinable impairment has been

established, an individual's symptoms and the effect(s) of those

symptoms on the individual's ability to function must be considered

both in determining impairment severity and in assessing the

individual's residual functional capacity (RFC), as appropriate. If the

adjudicator finds that pain or other symptoms cause a limitation or

restriction having more than a minimal effect on an individual's

ability to perform basic work activities, a “severe” impairment must

be found to exist. See SSR 96-3p ,

“Titles II and XVI: Considering

Allegations of Pain and Other Symptoms in Determining Whether a

Medically Determinable Impairment is Severe” and SSR 96-7p , “Titles

II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the

Credibility of an Individual's Statements.”

's

ability to perform basic work activities, a “severe” impairment must

be found to exist. See SSR 96-3p ,

“Titles II and XVI: Considering

Allegations of Pain and Other Symptoms in Determining Whether a

Medically Determinable Impairment is Severe” and SSR 96-7p , “Titles

II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the

Credibility of an Individual's Statements.”

Proceeding with the sequential evaluation process, when an

individual is found to have a medically determinable impairment that is

“severe,” the adjudicator must next consider whether the individual's

impairment(s) meets or equals the requirements of the Listing of

Impairments contained in appendix 1, subpart P of 20 CFR part 404.

Since RSDS/CRPS is not a listed impairment, an individual with RSDS/

CRPS alone cannot be found to have an impairment that meets the

requirements of a listed impairment. However, the specific findings in

each case should be compared to any pertinent listing to determine

whether medical equivalence may

exist. [4] Psychological manifestations

related to RSDS/CRPS should be evaluated under the mental disorders

listings, and consideration should be given as to whether the

individual's impairment(s) meets or equals the severity of a mental

listing.

For those cases in which the individual's impairment(s) does not

meet or equal the listings, an assessment of RFC must be made, and

adjudication must proceed to the fourth and, if necessary, the fifth

step of the sequential evaluation process. Again, in determining RFC,

all of the individual's symptoms must be considered in deciding how

such symptoms may affect functional capacities. Careful consideration

must be given to the effects of pain and its treatment on an

individual's capacity to do sustained work-related physical and mental

activities in a work setting on a regular and continuing basis

sequential evaluation process. Again, in determining RFC,

all of the individual's symptoms must be considered in deciding how

such symptoms may affect functional capacities. Careful consideration

must be given to the effects of pain and its treatment on an

individual's capacity to do sustained work-related physical and mental

activities in a work setting on a regular and continuing basis. See SSR 96-7p , “Titles II and XVI:

Evaluation of Symptoms in Disability

Claims: Assessing the Credibility of an Individual's Statements” and SSR 96-8p ,

“Titles II and XVI: Assessing Residual Functional Capacity in

Initial Claims.”

Opinions from an individual's medical sources, especially treating

sources, concerning the effect(s) of RSDS/CRPS on the individual's

ability to function in a sustained manner in performing work

activities, or in performing activities of daily living, are important

in enabling adjudicators to draw conclusions about the severity of the

impairment(s) and the individual's RFC. In this regard, any information

a medical source is able to provide contrasting the individual's

medical condition(s) and functional capacities since the alleged onset

of RSDS/CRPS with the individual's status prior to the onset of RSDS/

CRPS is helpful to the adjudicator in evaluating the individual's

impairment(s) and the resulting functional consequences.

In cases involving RSDS/CRPS, third-party information, including

evidence from medical practitioners who have provided services to the

individual, and who may or may not be “acceptable medical sources,”

is often critical in deciding the individual's credibility. Information

other than an individual's allegations and reports from the

individual's treating sources helps to assess an individual's ability

to function on a day-to-day basis and helps to depict the individual's

capacities over a period of time, thus serving to establish a

longitudinal picture of the individual's status

ces,”

is often critical in deciding the individual's credibility. Information

other than an individual's allegations and reports from the

individual's treating sources helps to assess an individual's ability

to function on a day-to-day basis and helps to depict the individual's

capacities over a period of time, thus serving to establish a

longitudinal picture of the individual's status. Such evidence

includes, but is not limited to:

- Information from neighbors, friends, relatives, or clergy;

- Statements from such individuals as past employers,

rehabilitation counselors, or teachers about the individual's

impairment(s) and the effects of the impairment(s) on the individual's

functioning in the work place, rehabilitation facility, or educational

institution;

- Statements from other practitioners with knowledge of the

individual, e.g., nurse-practitioners, physicians' assistants,

naturopaths, therapists, social workers, and chiropractors;

- Statements from other sources with knowledge of the

individual's ability to function in daily activities; and

- The individual's own record (such as a diary, journal, or

notes) of his or her own impairment(s) and its impact on function over

time.

Information from neighbors, friends, relatives, or clergy;

Statements from such individuals as past employers,

rehabilitation counselors, or teachers about the individual's

impairment(s) and the effects of the impairment(s) on the individual's

functioning in the work place, rehabilitation facility, or educational

institution;

Statements from other practitioners with knowledge of the

individual, e.g., nurse-practitioners, physicians' assistants,

naturopaths, therapists, social workers, and chiropractors;

Statements from other sources with knowledge of the

individual's ability to function in daily activities; and

The individual's own record (such as a diary, journal, or

notes) of his or her own impairment(s) and its impact on function over

time.

ith knowledge of the

individual, e.g., nurse-practitioners, physicians' assistants,

naturopaths, therapists, social workers, and chiropractors;

Statements from other sources with knowledge of the

individual's ability to function in daily activities; and

The individual's own record (such as a diary, journal, or

notes) of his or her own impairment(s) and its impact on function over

time.

In accordance with SSR 96-7p ,

“Titles II and XVI: Evaluation of

Symptoms In Disability Claims: Assessing The Credibility of An

Individual's Statements,” when additional information is needed to

assess the credibility of the individual's statements about symptoms

and their effects, the adjudicator must make every reasonable effort to

obtain additional information that could shed light on the credibility

of the individual's statements.

If the adjudicator determines that the individual's impairment(s)

precludes the performance of past relevant work (or if there was no

past relevant work), a finding must be made about the individual's

ability to perform other work. The usual vocational considerations (see 20 CFR 404.1560 - 404.1569a and 416.960 - 416.969a ) must be followed in

determining the individual's ability to perform other work. See also SSR 96-8p , “Titles II and XVI:

Assessing Residual Functional Capacity in Initial Claims.”

Many individuals with RSDS/CRPS are “younger individuals” ages 18

through 49 (see 20 CFR 404.1563 and 416.963 ).

Age, education, and work

experience are not usually considered to limit significantly the

ability of individuals under age 50 to make an adjustment to other

work, including unskilled sedentary

work. [5] However, a finding of

“disabled” is not precluded for those individuals under age 50 who do

not meet all of the criteria of a specific rule and who do not have the

ability to perform a full range of sedentary work

erience are not usually considered to limit significantly the

ability of individuals under age 50 to make an adjustment to other

work, including unskilled sedentary

work. [5] However, a finding of

“disabled” is not precluded for those individuals under age 50 who do

not meet all of the criteria of a specific rule and who do not have the

ability to perform a full range of sedentary work. The conclusion about

whether such individuals are disabled will depend primarily on the

nature and extent of their functional limitations or restrictions.

Thus, if it is determined that an individual is able to do less than

the full range of sedentary work, refer to SSR 96-9p , “Titles II and

XVI: Determining Capability to Do Other Work—Implications of a

Residual Functional Capacity for Less Than a Full Range of Sedentary

Work.” As explained in that Ruling, whether the individual will be

able to make an adjustment to other work requires

adjudicative judgment regarding factors such as the type and extent of

the individual's limitations or restrictions and the extent of the

erosion of the occupational base for sedentary work.

Effective Date:

This Ruling is effective on the date of its publication in the Federal Register .

Cross-References:

SSR 96-2p , “Titles II and XVI: Giving

Controlling Weight to Treating Source Medical Opinions,” SSR 96-3p ,

“Titles II and XVI: Considering Allegations of Pain and Other Symptoms

in Determining Whether a Medically Determinable Impairment is Severe,” SSR 96-5p ,

“Titles II and XVI: Medical Source Opinions on Issues

Reserved to the Commissioner,” SSR 96-7p , “Titles II and XVI:

Evaluation of Symptoms in Disability Claims: Assessing the Credibility

of an Individual's Statements,” SSR 96-8p , “Titles II and XVI:

Assessing Residual Functional Capacity in Initial Claims,” and SSR 96-9p ,

“Titles II and XVI: Determining Capability to Do Other

Work—Implications of a Residual Functional Capacity for Less Than a Full

Range of Sedentary Work.”

7p , “Titles II and XVI:

Evaluation of Symptoms in Disability Claims: Assessing the Credibility

of an Individual's Statements,” SSR 96-8p , “Titles II and XVI:

Assessing Residual Functional Capacity in Initial Claims,” and SSR 96-9p ,

“Titles II and XVI: Determining Capability to Do Other

Work—Implications of a Residual Functional Capacity for Less Than a Full

Range of Sedentary Work.”

[1] Except for statutory blindness.

[2] For individuals under age 18 claiming benefits under title

XVI, disability will be established if the individual is suffering

from a medically determinable physical or mental impairment (or

combination of impairments) that results in “marked and severe

functional limitations.” See section 1614(a)(3)(C) of the Act and 20 CFR 416.906 .

However, for clarity, the following discussions

refer only to claims of individuals claiming disability benefits

under title II and individuals age 18 or older claiming disability

benefits under title XVI. It should be understood that references in

this Ruling to the ability to do substantial gainful activity,

“RFC,” and other terms and rules that are applicable only to title

II disability claims and title XVI disability claims of individuals

age 18 or older are also intended to refer to appropriate terms and

rules applicable in determining disability for individuals under age

18 under title XVI.

[3] A medical source opinion that an individual is “disabled”

or “unable to work,” has an impairment(s) that meets or equals the

requirements of a listing, has a particular residual functional

capacity (RFC), that concerns whether an individual's RFC prevents

him or her from doing past relevant work, or that concerns the

application of vocational factors, is an opinion on an issue

reserved to the Commissioner. Every such opinion must still be

considered in adjudicating a disability claim; however, the

adjudicator will not give any special significance to such an

opinion because of its source

hat concerns whether an individual's RFC prevents

him or her from doing past relevant work, or that concerns the

application of vocational factors, is an opinion on an issue

reserved to the Commissioner. Every such opinion must still be

considered in adjudicating a disability claim; however, the

adjudicator will not give any special significance to such an

opinion because of its source. See SSR 96-5p for an additional

discussion of this issue.

[4] In evaluating title XVI claims for disability benefits for

individuals under age 18, consideration must be given to the

possibility of finding functional equivalence based on the

individual's impairment and related symptoms and their effects on

whether the individual's impairment(s) results in marked and severe

functional limitations.

[5] However, “younger individuals” age 45-49 who are unable to

communicate in English or who are illiterate in English, whose past

work was unskilled (or who had no past relevant work), or who have

no transferable skills, and who are limited to a full range of

sedentary work must be found disabled under rule 201.17 in Table No.

1 of appendix 2, of the Medical-Vocational Guidelines in 20 CFR part

404.