General Guideline Principles for Complex Regional Pain
Syndrome for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Complex Regional Pain Syndrome.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Medical Care for Complex Regional Pain Syndrome for workers compensation patients

The medical care and treatment necessary as a result of a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and occupational needs with a focus on returning to work, while attempting to restore the patient’s health to its pre-injury status to the extent that is practical.

Rendering Of Medical Services

Any medical professional who treats a patient under workers compensation must use the treatment recommendations as specified with regard to all work-related illnesses or injuries.

Positive Patient Response

Positive outcomes are primarily identified as objectively measurable functional increases. Positional tolerances, range of motion, strength, endurance, activities of daily living (ADL), cognition, psychological behaviour, and efficiency/velocity metrics that may be measured are just a few examples of objective functional benefits. When subjective reports of pain and function have anatomical and physiological linkage in relation to the injury, they may be taken into account and given relative weight.

Re-Evaluate Treatment

The clinician should either adjust or stop the treatment regimen if a specific treatment or modality is not yielding positive outcomes within a clearly specified timeframe. In the two to three weeks following the first visit and the subsequent three to four weeks, the physician should assess the effectiveness of the therapy or modality.

These timelines could be a little bit shorter for other non-musculoskeletal medical illnesses (such pulmonary, dermatologic, etc.) and a little bit longer for conditions that are innately mental health issues. In the event of an unexpectedly poor response to an otherwise rational intervention, the clinician should be motivated to reassess the diagnosis due to the recognition that therapeutic failure might occasionally be attributed to an inaccurate diagnosis or failure to respond.


The treatment of a work-related injury or disease should place a strong emphasis on educating the patient, their family, the employer, the insurance, the community, and those who make policy decisions.

Practitioners should create and use efficient educational plans and methods. A communication-based paradigm for education should always begin with the patient receiving comforting information.Without addressing concerns of individual and/or group patient education as a way to facilitate self-management of symptoms and avoidance of future harm, no treatment plan is complete.

Time Frames for Complex Regional Pain Syndrome for workers compensation patients


Generally speaking, the disease stages of acute, subacute, and chronic are defined as time periods:

  • Acute – disease lasts less than one month


  • Subacute – One to three month, and


  • Chronic – greater than three months

Initial Evaluation

The term “first evaluation” refers to the time period following an injury rather than when a specific physician initially analyses an injured worker in an office or clinical environment.

Diagnostic Time Frames

On the day of the accident, diagnostic testing must begin within a period of time determined by the doctor. In some cases, it may be necessary to speed up or slow down the time frames mentioned in this document.

Treatment Time Frames

Time frames for specific therapies begin after treatments have begun, not on the date of injury. It is widely accepted that the duration of treatment may be influenced by the severity of the disease, patient compliance, and availability of services. The speed of implementation may need to be faster or slower than what is described in this document, depending on the individual situation.

Delayed Recovery

If a patient does not improve six to twelve weeks after an injury, and if their symptoms do not match up with objective signs according to tests, then the diagnosis should be double-checked for accuracy. The treatment plan should also be re-evaluated at this time. Assessment for potential barriers to recovery (yellow flags/psychological concerns) should be continuous throughout the patient’s treatment when addressing a clinical problem that is not inherently a mental health issue.

After six to twelve weeks, other possible treatment programs like professional psychological or social evaluations should be looked into. Medics must watch out for existing psychological problems or new ones that could affect healing.

For issues that are immediately recognizable as mental health conditions (for example, when it is clear that the individual has an underlying mental disorder related to their job), referral to a mental health provider should take place much sooner.

For issues that are immediately recognizable as mental health conditions (for example, when it is clear that the individual has an underlying mental disorder related to their job), referral to a mental health provider should take place much sooner. The evaluation and management of delayed recovery does not necessitate the filing of a mental or psychological claim.

Treatment Approaches for Complex Regional Pain Syndrome for workers compensation patients

Active Interventions

As treatment progresses, active interventions that focus on the patient’s responsibility, such as therapeutic exercise and functional treatment, are generally given more attention than passive modalities. Passive and palliative interventions are usually seen as a way to help someone in an active rehabilitation program to reach their goals.

Active Therapeutic Exercise Program

As clinically indicated, active therapeutic exercise program goals should incorporate patient strength, endurance, flexibility, range of motion, sensory integration, coordination, cognition and behaviour. This includes being able to apply the skills you’ve learned in a work or community setting.

Diagnostic Imaging And Testing Procedures for Complex Regional Pain Syndrome for workers compensation patients

Selection of diagnostic techniques and evaluation of findings should be based on clinical data collected through history taking and physical examination. When deciding which diagnostic procedures to use, many factors are taken into account such as: how reliable the procedure is in making a diagnosis; if the risks of undergoing the procedure are worth the benefits; what technology is available; if the patient can handle it physically and/or mentally; and finally, how familiar with performing it the practitioner.

When a diagnostic examination, joined with clinical data, gives sufficient information to make an accurate diagnosis, no further testing is necessary. When the initial study was of insufficient quality to make a diagnosis.

However, a subsequent diagnostic procedure including a repeat of the original (same) procedure can be performed when the specialty physician (e.g. physiatrist, sports medicine doctor or other appropriate specialist) radiologist or surgeon documents that the first study was of poor quality. The MTG allows for a repeat or supplementary diagnostic test in such circumstances.

Although it may involve additional costs, repeat imaging and other tests may be necessary to monitor a patient’s progress or response to treatment. Repeat diagnostic tests (e.g., imaging scans) during the course of treatment to re-evaluate or stage the condition when there is a progression of symptoms or findings, prior to surgical operations and/or therapeutic injections when clinically indicated, and following surgery to track the healing process.

Repeat examinations, such as x-rays (particularly CT scans), necessitate a change in perspective. Repeat procedures result in an increase in overall radiation exposure and associated hazards.

A diagnostic imaging procedure may provide more information than other procedures, or it may provide unique information. In conclusion, being judicious about the procedure(s) you choose for a single diagnosis, complementary procedures done in combination with procedures(s), or the proper order of multiple procedures will ensure maximum accuracy, minimise any negative effects on patients, and optimise efficiency by preventing duplication or extra steps.

Surgical Interventions for Complex Regional Pain Syndrome for workers compensation patients

Surgery should only be considered in the context of projected functional results. In terms of surgical treatment by itself, the term “cure” is typically misleading. Every surgical operation must be supported by evidence of a strong relationship between clinical symptoms, clinical trajectory, and imaging and other diagnostic testing.

A thorough integration of these criteria must result in a precise diagnosis with a confirmatory finding of the pathologic condition (s). Surgery can only be used to cure pain if there is a direct link between the pain’s symptoms as well as the cause, which must be proven objectively.It is always advisable to consult the patient when making decisions.

The patient should be given the chance to comprehend the advantages and disadvantages of surgery, the possibility of rehabilitation as an alternative when appropriate, the outcomes based on evidence, and the particular surgical experience.

Pre-Authorization for Complex Regional Pain Syndrome for workers compensation patients

With the exception of some procedures, all diagnostic imaging, testing, non-surgical, and surgical therapeutic procedures, as well as other therapies, that meet the criteria of the Workers Compensation Board Medical Treatment Guidelines and are based on a proper application of the Medical Treatment Guidelines, are thought to be approved. On the list of pre-authorized operations, these are not present.Pre-authorization from the carrier is required before executing any of these procedures by providers.

Pre-authorization is also necessary for second or subsequent treatments (the repetition of a surgical procedure due to failure of, or incomplete success from, a previous surgical procedure conducted, if the Workers Compensation Board Medical Treatment Guidelines do not specifically cover multiple procedures).

Psychological/Psychiatric Evaluations for Complex Regional Pain Syndrome for workers compensation patients

Evaluations of the patient’s mental health may be necessary to establish, support, or confirm a diagnosis in some cases. Obviously, the depth and length of assessments and/or interventions conducted by mental health specialists may differ, especially depending on whether:

There is a mental health issue that is related to or results from the medical injury or sickness that is at issue in the claim in question, or there is a mental health issue that is an intrinsic component of the claim’s underlying clinical issue; The underlying problem in this claim is a mental health problem.

Or there is a mental health problem that is secondary or consequential to the medical injury or illness that is at issue in this claim. Or there is a pre-existing, unrelated mental health issue that has been made worse by, or is impeding recovery from (or both) the medical injury or illness that is at issue in this claim.

Psychological tests can be a valuable component of the evaluation in identifying associated psychological, personality and psychosocial issues. Both screening and psychometric tests are incapable of making a diagnosis, despite the fact that these instruments may be able to make a suggestion. Only after careful examination of all pertinent information, including that obtained from a complete history and clinical interview, may a diagnosis be established.

Strongly desirable is a professional who is proficient in the patient’s mother tongue.When such a service provider is not accessible, a qualified language interpreter must be hired.

A single visit for the initial psychiatric or psychological encounter should be sufficient when evaluating for a pre-existing, unrelated mental health issue that has been exacerbated by, is impeding the recovery from, or is both, a work-related medical injury or illness.

Normally, care would be continued by the previous treating provider.If the results of the initial consultation indicate that psychometric testing is necessary, the time required for such testing should not exceed an additional three hours of professional time.

More extensive diagnostic and therapeutic interventions may be clinically indicated for conditions where a mental health issue is a key component of the initial claim or where a mental health issue is secondary to or consequential to the work-related illness or injury that is part of the claim in question. These mental health conditions are covered in detail in the Medical Treatment Guidelines.

Personality/Psychological/Psychosocial Intervention for Complex Regional Pain Syndrome for workers compensation patients

When an intervention is suggested after a psychological examination, it should be put into action as quickly as possible.You can use this by alone or in combination with other therapeutic approaches.A treatment plan with quantifiable behavioural goals, time constraints, and specific interventions must be prepared for all psychological and psychiatric interventions.

  • Two to eight weeks for effects to manifest.


  • The ideal time frame is between six and three months.


  • Three to six months at the most.


  • Counselling is meant to speed up functional recovery rather than to postpone it.

Psychological treatment for PTSD:

  • A three to six month period is ideal.


  • Nine to twelve months at the most.

Longer supervision and treatment may be necessary for some patients, and if additional treatment is recommended, the authorised treating practitioner should report the nature of the psychological factors and project a reasonable functional prognosis every four weeks for the first six months of treatment.

Such paperwork should be given every four to eight weeks for treatment that is anticipated to last six to twelve months. Such documentation should be given every eight to twelve weeks for long-term treatment that lasts more than twelve months. To ensure smooth, continuous, and uninterrupted treatment, all parties should work to maintain continuing communications.

Functional Capacity Evaluation (FCE) for Complex Regional Pain Syndrome for workers compensation patients

An extensive or more focused evaluation of the several facets of function in relation to the patient’s capacity to resume work is known as a functional capacity evaluation.Various characteristics of competitive employment, including endurance, lifting (dynamic and static), postural tolerance, particular range-of-motion, coordination, and strength, worker habits, and employability, may be assessed.

Components of this evaluation may include:

  • musculoskeletal screen.


  • cardiovascular profile/aerobic capacity.


  • coordination.


  • lift/carrying analysis.


  • job specific activity tolerance.


  • maximum voluntary effort.


  • pain assessment/psychological screening.


  • non-material and material handling activities.


  • cognitive and behavioural.


  • visual.


  • sensory perceptual factors.

In most situations, it is possible to determine if a patient can resume working without using an FCE.

When the treating physician is unable to reach a definitive decision regarding work status at case closure, an FCE may be taken into account at the time of MMI after making reasonable prior attempts to return to full duty over the course of treatment.For any reason, including one to support a therapy strategy, an FCE is not recommended early on in a treatment regimen.

The treating physician is in charge of comprehending and taking into account the job responsibilities when an FCE is being utilised to determine return to a specific employment site.The determination of work limits cannot be made only based on FCEs.

The authorised treating physician is required to interpret the FCE in light of each patient’s unique presentation, as well as their medical history and subjective experiences.FCEs shouldn’t be the only factor considered when diagnosing malingering.

Return To Work for Complex Regional Pain Syndrome for workers compensation patients

For the purposes of these recommendations, “return to work” refers to any task or responsibility that the patient is capable of carrying out safely. The patient’s regular work may not be included. In the treatment and rehabilitation plan, it should be included to determine a patient’s readiness to return to work.

Normally, it is discussed at each outpatient visit.Any treatment plan should include a description of the patient’s condition and task restrictions, which should serve as the rationale for restricting work duties as necessary. Early return to work ought to be the main objective of occupational injury treatment.

Since the likelihood of getting an injured worker back to work decreases over time, the emphasis of these guidelines is on getting patients to proceed along a continuum of care and get back to work.

Job Site Evaluation for Complex Regional Pain Syndrome for workers compensation patients

To learn more about the unique or particular requirements of the patient’s pre-injury employment, the treating physician may speak with the employer or the employer’s designee in person, through video conference, or over the phone.

This could include a description of the physical demands of the job, the requirement for repetitive tasks, the lifting of heavy objects, awkward or static postures, environmental exposures, psychological stressors, and other elements that could prevent re-entry, increase the risk of reinjury, or interfere with the healing process.

Inquiries should be made about modified duty work settings that align with the patient’s condition in light of proposed work activities/demands in modified duty jobs when returning to the patient’s previous job tasks or setting is not practical given the clinically determined restrictions on the patient’s activities.

The physician would ideally learn the most from an on-site examination of the work environments and activities, although it is acknowledged that this may not always be possible.If the company provides job-related films, CDs, or DVDs, they can be a great source of information, as can video conferences held from the workplace, ideally a workstation or work area.

One or two contacts each time

  • First contact: The patient is functioning and capable of doing some work.
  • Second contact: The patient has progressed to the point where he or she is able to handle higher functional demands in a workplace.

The doctor must record the discussion.

Guideline Recommendations And Medical Evidence

The scientific medical literature cited in support of the guidelines has not been independently reviewed or evaluated by the Workers Compensation Board or its Medical Advisory Committee. Instead, they have relied on the development process of other guidelines that are used and cited in these Guidelines.

Experimental/Investigational Treatment

These Guidelines prohibit the use of experimental or investigational medical treatments that have not received FDA approval for any purpose, application, or indication.

What our office can do if you have workers compensation injuries

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.


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Dr. Nakul Karkare

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.