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Education
 
Recommendations to Physicians Performing and Impairment Rating for a Patient with CRPS
By Peter Moskovitz, MD

Physicians may be called upon to perform an impairment rating for a patient with complex regional pain syndrome (CRPS). The rating can be used to fulfill statutory, regulatory or administrative requirements, or to assess third-party liability in either a workers’ compensation or personal injury setting. The physician does not rate disability; that is the responsibility of the agency requesting the impairment rating.

The Guides to the Evaluation of Permanent Impairment, Fifth Edition, published by the American Medical Association (The Guides), is a standard reference. Some of its definitions are particularly useful: Impairment is defined as “a loss, loss of use, or derangement of any body part, organ system, or organ function.” A disability is “an alteration of any individual’s capacity to meet personal, social, or occupational demands because of an impairment.” A physician may give an opinion about the relationship of impairment and disability for a particular patient, but that is not a function of evaluating impairment.

There are many methods of evaluating global function or capacity that is the obverse of disability. The Guides lists a number of such instruments (Table 1-3, page 6) but they are not the focus of The Guides, nor do they fulfill its intent, since they reflect the impact of impairment on activities of daily living, excluding work. They are insufficient for a disability determination for which the impairment rating is intended.

The physician must understand whether the requesting agency requires a “whole person” or an “organ system” rating. CRPS does not lend itself well to “organ system” rating, wherein individual functions of motion, sensibility, strength, circulation, bone loss, and atrophy, among others, are rated and combined to give an impairment rating for an extremity. If the request if for an “organ system” rating, the process will be tedious. “Whole person” ratings are more appropriate in CRPS and, fortunately, the Fifth Edition of The Guides makes specific reference to CRPS.

Section 13.8, page 343-344 (Criteria for Rating Impairments Related to Chronic Pain), gives a brief, but rather masterful summary of CRPS and instructions for rating impairments. Each upper extremity is rated separately according to Table 13-22, page 343, and lower extremity function is rated according to Table 13-15, page 336, “Criteria for Rating Impairments Due to Station and Gait Disorders.” The Guides does not indicate that such ratings according to Tables 13-15 and 13-22 are exclusive. It leaves open the discretion to rate specific impairments due to the root cause of the CRPS, such as a fracture, joint injury or neurological injury, either central or peripheral.

If ratings from multiple tables, or two extremities from one table apply, then they must be combined according to the “Combined Values Chart), page 604. The chart contains instructions for its use. It is obvious that a percentage impairment rating cannot exceed 100%, as would be possible if combining values were additive.

Updated July 19, 2005

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