Court Opinion

ID: 9522002
Source: CourtListenerOpinion
Date Created: 2023-08-07 02:16:42.62618+00
Date Added: 2024-06-11T13:02:11.861998
License: Public Domain

Dooley, J.,
¶ 37. dissenting. In decision after decision, we have held that our main goal in construing statutes is to implement the intent of the Legislature. In this case, the majority has construed a statute to weaken its central purpose to bring objectivity, consistency and predictability to the workers’ compensation impairment-determination process and the requirements of this process to the point where it is difficult to find any remaining point in having the statute. The majority reaches this conclusion by exploiting what it perceives as a loophole in the drafting of the statute. It is difficult to discern any reason why the Legislature would create such a loophole, and the majority gives us none except to say that we should construe the statute to benefit the claimant. I cannot join a decision the result of which is so clearly contrary to the intent of the Legislature, and therefore dissent.
¶ 38. Our responsibility to construe the statute arises in an area where there has been tremendous controversy over what evidence must be shown to establish the presence of a condition — Complex Regional Pain Syndrome, known by its acronym of CRPS. If the statute’s purpose of bringing objectivity and consistency to the impairment-rating process does not produce that effect for CRPS, where it is most needed, it is a paper tiger. Put another way, the majority’s resolution of this case may be appropriate for the majority of impairment ratings covered by the American Medical Association Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition. This is because *31most impairment ratings are not dependent on a particular diagnosis. CRPS represents a critical exception to this standard method of impairment rating. For CRPS, the policy of the Guides is that there is no applicable impairment absent a diagnosis of CRPS pursuant to the Guides. In other words, the proper impairment rating under Chapter 16 of the Guides — the chapter used in this case — is zero. I would hold, as did the Commissioner and the trial court, that an impairment rating due to CRPS using Chapter 16 of the AMA Guides Fifth Edition necessarily requires that CRPS be diagnosed according to the criteria in that chapter.
¶ 39. Some background is necessary to understanding why the drafters of the Guides Fifth Edition took the approach they did with respect to CRPS. The underlying issue is explained in a recent commentary:
The basic diagnostic problem of this condition — severe, unrelenting pain out of proportion to the inciting injury — is significantly complicated by the subjective nature of the pain and the need for clear objective measures for the basis of the discomfort. Added to this mix is the fact that there is no diagnostic test specific for CRPS. In a medical setting, these issues create debate over the accuracy of the diagnosis and appropriate treatment. In a compensation context, subjective pain that is out of proportion to the injury is a recipe for unrelenting controversy.
S. Hodge, J. Hubbard & K. Armstrong, Complex Regional Pain Syndrome — Why the Controversy?, 13 Mich. St. U. J. Med. & L. 1, 3 (2009).10 The continuing education program of the American Academy of Neurology has included a classification of CRPS as a “mythical concept.” R. Barth, A Historical Review of Complex Regional Pain Syndrome in the ‘Guides Library’, Guides Newsl. (Amer. Med. Assoc., Chicago, 111.), Nov./Dec. 2009, at 1 (citations omitted).11
*32¶ 40. The AMA rated CRPS in two places in the Fifth Edition of the Guides,12 a split designed to be “reflective of differences in the clinical approach of different specialties to different conditions and/or organ systems.” Letter from Michael Maves, Exec. V.P. of Amer. Med. Assoc., to Anthony Kirkpatrick, Dep’t of Anesthesiology, U. S. Fla. (Oct. 28, 2004), available at http://www.rsdfoundation.org/ test/AMAreferences.html. The diagnosis and impairment rating in this case are governed by Chapter 16 of the Guides, so I begin my discussion with that chapter, and return to Chapter 18 below.
¶ 41. A finding of CRPS under Chapter 16 “should be conservative and based on objective findings” because many of the symptoms can have different causes. AMA Guides at 496. Thus, under this chapter a diagnosis must be predicated “upon a preponderance of objective findings that can be identified during a standard physical examination and demonstrated by radiological techniques.” Id. It requires that at least eight of eleven possible objective findings be made. Id. These findings must involve objective evidence of disease and cannot simply be based on symptoms. Id.
¶ 42. Immediately following the diagnosis requirement in Chapter 16, the Guides set out the methodology for determining impairment for CRPS I and CRPS II.13 There is no suggestion *33that the impairment determination methodology can be used separately from the diagnosis. Indeed, the placement of the impairment determination instructions right after the diagnosis instructions suggests the contrary intent. The continuing guidance from the AMA is consistent with this interpretation. The AMA publishes a Guides Newsletter, which it calls “a complement to” the AMA Guides. AMA Guides Newsletter, https://commerce.amaassn.org/store/catalog/productDetail.jsp?product_id=prodl240005& sku_id=skul240013&navAction=push. In a 2006 clarification of the various ways that CRPS can be rated, the editors of the Guides Newsletter stated: “Do NOT consider the diagnosis of CRPS type 1 for impairment rating purposes unless 8 of the 11 criteria have been documented to be present concurrently.” Rating Impairment for CRPS Type 1, Guides Newsl. (Amer. Med. Assoc., Chicago, 111.), Mar./Apr. 2006, at 10.
¶ 43. It is important to emphasize that the AMA approach in Chapter 16 specifically and intentionally rejected the approach of the International Association for the Study of Pain (IASP).14 In a series of articles in the AMA Guides Newsletter, Dr. Robert Barth explained that the AMA Guides have “recommended against the use of the IASP protocol for CRPS since 1997 (due to predictions, later confirmed, that the protocol would lead to overdiagnosis).” R. Barth, A Historical Review of Complex Regional Pain Syndrome in the ‘Guides Library’, Guides Newsl. (Amer. Med. Assoc., Chicago, Ill.), Nov./Dec. 2009, at 4. He added that the AMA Guides Fifth Edition, at issue here, “continued the call for clinicians to avoid utilization of the IASP’s protocol, in favor of an extensive differential diagnostic process seeking to eliminate alternative diagnoses.” Id.-, see also R. Barth and T. Bohr, Challenges in the Diagnostic Conceptualization of CRPS-1 (Formerly Conceptualized as RSD), Part 1, Guides Newsl. (Amer. Med. Assoc., Chicago, 111.), Jan./Feb. 2006, at 5 (“[T]he IASP protocol is inherently flawed because it represents a departure from epidemiologic guidelines, because it is indistinguishable from alternative diagnostic possibilities, and because it is self-contradictory.”); R. Barth and T. Bohr, Challenges in the Diagnostic Conceptualization of CRPS-1 (Formerly Conceptualized as RSD), Part 2, Guides Newsl. (Amer. Med. Assoc., Chicago, 111.), Mar./Apr. 2006, *34at 2 (“In summary, the logical ramifications of the fourth criterion from the IASP protocol actually cause CRPS-1 to be a diagnosis that never can be credibly adopted for any individual case”). The criticism has also come from a study in the journal Pain in 1999, which found that “the majority of cases that satisfied IASP diagnostic criteria were actually from samples of people who were known in advance to not have CRPS I.” R. Barth, A Historical Review of Complex Regional Pain Syndrome in the ‘Guides Library’, Guides Newsl. (Amer. Med. Assoc., Chicago, 111.), Nov./ Dec. 2009, at 3 (citing S. Bruehl, et al., “External Validation of IASP Diagnostic Criteria for Complex Regional Pain Syndrome and Proposed Research Diagnostic Criteria,” 81 Pain 147-54 (1999)).
¶ 44. An even stronger indication of the required relationship between the impairment ratings for CRPS is that, as referenced above, the Guides offer two ways of diagnosing CRPS and each has a separate, unique method of calculating impairment once the diagnosis is made. The second method is in Chapter 13. Chapter 13 (“The Central and Peripheral Nervous System”), while it contains no checklist of necessary clinical findings for CRPS, gives examples of what clinical findings and radiographic results may lead to such a diagnosis. AMA Guides at 343. It emphasizes that “diagnosis is key and is based on clinical criteria.” Id. It contains a separate chart to rate an impairment. Id.15
¶45. The presence of a separate method of diagnosis and calculating impairment in Chapter 13 is a clear demonstration that the diagnoses and impairment ratings for CRPS are inextricably intertwined. The drafting is such that the impairment ratings are usable only with the applicable diagnosis.
¶46. Additionally, the Guides make clear that permanent impairment ratings are to be made only once a patient has reached “maximal medical improvement” (MMI). AMA Guides at 19. This phrase “refers to a date from which further recovery or deterioration is not anticipated, although over time there may be some *35expected change.” Id. It is on that date that the existence or lack of evidence of the objective signs of CRPS must be evaluated. See Westmoreland Reg’l Hosp. v. Workers’ Comp. Appeal Bd., 29 A.3d 120, 129 (Pa. Commw. Ct. 2011) (noting that the AMA Guides required an impairment rating of zero for CRPS because “[c]laimant did not exhibit objective symptoms ... at the time of the [impairment rating evaluation]” (emphasis added)). The editors of the Guides Newsletter have emphasized the particular importance of reaching this stage before rating CRPS cases for permanent impairment as “maximal medical improvement . . . can be slow.” Rating Impairment for CRPS Type 1, Guides News1. (Amer. Med. Assoc., Chicago, 111.), Mar./Apr. 2006, at 10.
¶ 47. This need to reach a medical end. result leads to a difference over the record between the majority and this dissent. The majority describes Dr. Wieneke as agreeing that claimant had CRPS at the point of his first evaluation, although “the syndrome had resolved by the time claimant reached a medical end.” Ante, ¶ 26. From this, the majority argues that there is an inconsistency in this dissent because I accept that claimant had CRPS for purposes of medical rehabilitation or temporary disability benefits but would hold that when claimant reached an end result he “was ineligible for evaluation of any permanent impairment.” Id. There is no inconsistency, and the majority failed to describe the essential elements of Dr. Wieneke’s opinions.
¶48. The statute we are construing applies only to “[pjermanent partial disability benefits.” 21 Y.S.A. § 648(b) (emphasis added). The AMA Guides are for “Evaluation of Permanent Impairment.” (Emphasis added.) Dr. Wieneke never opined that claimant had a permanent impairment from CRPS. Indeed, in his first opinion, he stated that claimant had CRPS but could return to work in six weeks. He made it clear that claimant had not reached a medical end result. In his second opinion, he said that claimant had reached a medical end result and diagnostic points for CRPS “are no longer present.” He found that claimant had a work injury and assigned a whole body impairment of three percent based on restricted shoulder functionality and upper body pain.
¶49. It is perfectly possible that a claimant could have CRPS, but with the passage of time and medical intervention have no *36permanent impairment from CRPS. If we believe Dr. Wieneke, that is precisely what occurred in this case. Under Dr. Wieneke’s conclusion, claimant was eligible “for evaluation of any permanent impairment,” but not one based on a diagnosis of CRPS and not one based on a CRPS impairment rating. How the Department of Labor treated temporary disability compensation or rehabilitation or medical benefits is irrelevant to this case because the statute at issue does not apply to these items. There is nothing “incongruous” in a holding that claimant is not entitled to a CRPS impairment rating because he does not have CRPS as a permanent condition that results in a permanent impairment.
¶ 50. With this background in mind, I turn to the question before us. The statute in issue reads:
Any determination of the existence and degree of permanent partial impairment shall be made only in accordance with the whole person determinations as set out in the fifth edition of the American Medical Association Guides to the Evaluation of Permanent Impairment.
21 V.S.A. § 648(b). The majority reads the language as saying that only the degree of permanent partial impairment must be taken from the Guides; any other step in the determination can come from anywhere, no matter what is the basis for the medical diagnosis of CRPS. As I understand the majority opinion, it holds that the impairment ratings for CRPS as contained in § 16.5(e) can be used with any CRPS diagnosis, whether or not it meets the standards of the AMA Guides or any other professional standards, or any other diagnosis where in the clinical judgment of the physician witness the CRPS impairment standards best fit. See ante, ¶ 22.
¶ 51. While I find this interpretation creative to maximize a worker’s recovery, I think it is inconsistent with the structure of the Guides, the language of the statute, and, most important, the intent of the Legislature. Indeed, the statutory requirement is essentially eliminated.
¶ 52. The first point is obvious from my opening discussion of the drafting of the Guides. The permanent partial impairment ratings set out in the Guides for CRPS are wholly dependent on the corresponding diagnosis of CRPS under the standards in *37Chapter 13 or those in Chapter 16. It is not permissible to calculate an impairment rating under Chapter 16 based on a CRPS diagnosis under Chapter 13, as the majority would allow. Even less is it permissible to import a CRPS diagnosis from outside the Guides to go with a CRPS impairment rating under either chapter.16 As one court has held recently in similar circumstances, where the worker does not meet the Guides’ requirements for a diagnosis of CRPS, “the AMA Guides require a zero impairment rating for that condition.” Westmoreland Reg’l Hosp., 29 A.3d at 129; see also id. at 126 (“Dr. Klein could not assign more than a zero percent impairment to [the CRPS] condition without violating the AMA Guides”).
¶ 53. The majority gives a number of reasons why the Guides do not require the opposite result in this case. First, the majority states: “ ‘[Diagnosis’ per se is not intrinsic to the identification or measurement of many impairments in the AMA Guides.” Ante, ¶ 16 (emphasis added). For the reasons I have stated above, CRPS as rated in Chapter 16 is one of the impairments for which diagnosis is intrinsic. If the majority accepts the proposition that there are instances where the impairment rating is dependent on the diagnosis under the Guides, CRPS cases fit that description exactly.
¶ 54. Second, the majority argues that the fact that the Guides provide two different methods of diagnosing CRPS supports its position. Ante, ¶ 17. Apparently, the majority would conclude that the choices work like a Chinese menu — however CRPS is diagnosed, the claimant’s physician can chose whichever impairment rating methodology the physician desires, even if it is not paired with the diagnosis method. There being no clinical reason behind the choice, it will be unsurprising that the claimant, supported by the physician, will choose the impairment rating that will maximize the whole body rating and thus the amount of compensation. Because there is no medical reason for the choice, it is hard to see this as other than playing games with the system. That this is allowed, indeed almost certain, under the majority’s rationale is a strong reason to reject that rationale.
¶ 55. As for the language of the statute, the majority has adopted an interpretation of § 648(b) that is not compatible with *38its language and does not show a “compelling indication of error” to overturn the Commissioner’s interpretation. The majority essentially reads two phrases out of the statutory language — “existence and” and “whole person determinations.” Even under the majority’s flexible approach, claimant must show a permanent impairment. The medical evidence in this case provides only one diagnosis that supports a permanent impairment of the scope for which claimant seeks compensation — that is, CRPS. If the “existence” question is controlled by the Guides — as the statute says it must be — the answer is that, whatever claimant’s symptoms, they are not caused by CRPS and do not show a permanent impairment of the magnitude of a CRPS impairment. As the Pennsylvania court concluded in Westmoreland, 29 A.3d at 129, the correct impairment rating in this case for CRPS under the Guides is zero.
¶ 56. The statute provides that “[a]ny determination of the existence and degree” of impairment shall be made “in accordance with the whole person determinations” in the Guides. 21 V.S.A. § 648(b). As I discussed earlier, the determinations of CRPS in the Guides are based on a diagnosis under the Guides’ requirements. Similarly, a determination in an individual case must follow the Guides’ process, which starts for CRPS with a diagnosis of CRPS under the Guides’ requirements. As I stated in opening this dissent, there are many parts of the Guides in which a conforming diagnosis is not part of the process of determining an impairment rating. That is, of course, the reason that the statute does not specifically refer to a diagnosis; nor does it refer to other parts of the determination process by the label attached by the Guides for that step. Where the Guides do require a specific diagnosis as part of the process of determining an impairment rating, the statute requires that determination process to be followed. The determination process for CRPS requires a CRPS diagnosis.
¶ 57. Narrowly parsing the language of § 648(b), the majority arrives at an interpretation of the statute that allows evasion of its obvious intent. The . majority interpretation makes the words “existence” and “determination” superfluous so no case would ever turn out differently if those words were omitted. In this case, the Guides clearly state that there is no permanent partial impairment due to CRPS unless the condition is diagnosed under its requirements. That is the “determination” required by the Guides, and in this case, it is a determination of the existence or nonexistence of *39a permanent partial impairment. The Commissioner’s construction of the statute is not only reasonable; it is compelled by the statutory language.
¶ 58. The evasion becomes even greater if we accept the majority’s holding (addressed below) that, where the claimant’s condition does not meet the objective findings requirements for a CRPS diagnosis, the physician can simply rename the claimant’s condition to something else — or as lacking an established name — and proceed to an impairment rating as if claimant has CRPS. Ante, ¶ 32. In that situation, the “existence” of a permanent impairment is not determined under the Guides and the physician is not making the whole person determination under the Guides.
¶ 59. As support for its construction of the statute, the majority relies upon the decision of the Kentucky Supreme Court in Tokico (USA), Inc. v. Kelly, 281 S.W.3d 771 (Ky. 2009), a decision that is binding upon us only if we find it persuasive. Not surprisingly, I do not find it persuasive. The majority reaches its conclusion in this case based on thirty-six paragraphs of analysis. The court in Tokico reaches its result based on five sentences of analysis in one paragraph. Its conclusion is actually one sentence: “Diagnosing what causes impairment and assigning an impairment rating are different matters.” Id. at 774. This simplistic statement assumes that the impairment rating is not dependent on the diagnosis as part of the impairment-rating-determination process. The assumption is wrong for CRPS.
¶ 60. I also note that the statute in Tokico is more narrowly, drawn than the Vermont statute. It contains neither the “existence” or “determination” language that is central to the proper interpretation of § 648(b). For this reason, the superior court found Tokico17 unhelpful “as the underlying statute is dissimilar.” I agree with the superior court’s assessment.
¶ 61. The most significant of the majority’s reasons for its interpretation, and in my view the most concerning, comes under the general heading of discretion. This is based on the Guides’ “latitude to examiners to exercise discretion in choosing the best rating methodology for a given condition” in selecting a specific rating, and to use judgment in dealing with unrated conditions. Ante, ¶ 30. In the majority’s view, this discretion means that if a *40physician cannot make a diagnosis of CRPS because the required number of objective symptoms is not present, the physician can consider the condition unrated and use the CRPS impairment rating anyway. Ante, ¶ 32. I consider this to be an evasion of the requirements of the statute that makes the statutory requirement meaningless.
¶ 62. In many instances, the ratings leave a great deal of room for clinical judgment in reaching ratings. When they do not give such discretion, however, doctors are not allowed to use their unrestricted judgment to abandon the specific direction of the Guides. Discretion under the Guides does not include rejection of specific, explicit requirements.
¶ 63. This is the holding of In re Rainville, 732 A.2d 406 (N.H. 1999). The New Hampshire statute requires that certain permanent partial impairment ratings be made “in accordance with the percent of the whole person specified for such bodily losses in the most recent edition of ‘Guides to the Evaluation of Permanent Impairment’ published by the American Medical Association.” Id. at 411. In Rainville, the petitioner’s doctor diagnosed the petitioner with “myofascial pain,” resulting in twenty percent loss of the function of each shoulder, and neck pain. The doctor used the Guides to calculate the whole person impairment of eighteen percent. The New Hampshire Compensation Appeals Board rejected the medical opinion under the statute because the Guides do not recognize myofascial pain. The Supreme Court reversed, holding: “[I]n view of the AMA Guides’s own instructions and our liberal construction of [the statute] ... , we hold that if a physician, exercising competent professional skill and judgment, finds that the recommended procedures in the AMA Guides are inapplicable to estimate impairment, the physician may use other methods not otherwise prohibited by the AMA Guides.” Id. at 413. The court went on to add: ‘We caution that our decision does not permit physicians or ¡ claimants to deviate from procedures simply to achieve a more desirable result. To satisfy the statutory requirements . . . , a deviation must be justified by competent medical evidence and be consistent with specific dictates and general purpose of the AMA Guides.” Id. It also added: “Whether and to what extent an alternative method is proper, credible, or permissible under the AMA Guides are questions of fact to be decided by the board.” Id.
¶ 64. Here, the majority is trying to use the discretion in the Guides exactly in the way that Rainville rejects. The “specific *41dictates” of the Guides establish the permissible methodologies for determining an impairment rating for CRPS; they do not leave room for a physician to use a different one. Where a condition is unrated, the Guides allow discretion in applying ratings by analogy. Where a condition is rated, and the Guides clearly and specifically state what evidence a physician must find to use that rating, the physician cannot apply the rating without that evidence.
¶ 65. There is another important part of the Rainville opinion — the court’s specific holding that whether a deviation from the Guides is appropriate is a determination of fact. In this case, both the Commissioner and the superior court found that they were required by statute to use the diagnosis requirements for CRPS in Chapter 16, which led them to rule against claimant. It is important to observe, however, that claimant never argued below or in this Court for the appropriateness of a deviation' from the Guides in the style of Rainville — rather, he makes a purely legal argument that a diagnosis under the Guides is not necessary. Thus, neither the Commissioner nor the superior court was called upon to do specific fact-finding required by Rainville.
¶ 66. There is a broader point here. Claimant never argued that a physician can use the CRPS rating section of the Guides “even if an individual’s condition (or diagnosis) is not the condition (or diagnosis) for which that section is specifically designed.” Ante, ¶ 32 (emphasis omitted). The broad dicta of the majority’s decision, dicta that will have more far-reaching effect than the specific holding with respect to CRPS or the construction of § 648(b), has been reached with no consideration by the Commissioner, who has primary jurisdiction over workers’ compensation cases, nor by the superior court, and with no briefing or argument in this Court, under the guise that the majority is simply explaining its reasons for its statutory construction decision. It is the equivalent of repealing § 648(b). It is inappropriate to render this kind of decision in this way in this case.
¶ 67. Finally, as I stated in the opening paragraph, the purpose of § 648(b) is to bring objectivity, consistency and predictability to the impairment determination process. See, e.g., Redd v. Kansas Truck Ctr., 239 P.3d 66, 76 (Kan. 2010); Harvey v. H.C. Price Co., 957 A.2d 960, 965 (Me. 2008); see also 4 A. Larson & L. Larson, Workers’ Compensation Law § 80.07[2] (2011); AMA Guides at 4. The majority’s holding goes exactly in the opposite direction, *42introducing subjective decision-making into the diagnosis that is determinative of the Guides’ impairment rating. It eliminates objectivity and predictability in the impairment determination process. In view of the track record of subjective CRPS evaluations, the determination involved here is the last that should deviate from the Guides. See Hodge, Hubbard & Armstrong, supra, at 20 (“It is common knowledge that in the battle of the experts, both sides are capable of securing witnesses who will testify about whether the employee does or does not have CRPS.”).
¶ 68. I return to the central policy that our primary objective in interpreting statutes is to implement the intent of the Legislature. See In re Carroll, 2007 VT 19, ¶ 9, 181 Vt. 383, 925 A.2d 990. The majority has found an ambiguity in the legislative drafting that it can exploit, but it has not found a reason why the Legislature would ever intend its construction of the statute, which so clearly undermines its intent. Indeed, I urge the Legislature to take a close look at § 648(b) in light of this decision. It no longer provides meaningful regulation of the impairment rating system.
¶ 69. I dissent. I would affirm the well-reasoned decisions of the Commissioner and the superior court.
¶ 70. I am authorized to state that Judge Eaton joins this dissent.

 For an impression of the medical controversy see the interchange between the Chairman of the Scientific Advisory Committee of the International Foundation for RSD/CRPS and the Executive Vice-President of the American Medical Association. Int’l Research Found, for RSD/CRPS (Nov. 30, 2009), http://www.rsdfoundation.org/ test/AMAreferences.html.

I have included this background, not to take sides in the controversy over how to diagnose CRPS, but to point out why the AMA took the position it did in the *32Guides and why the separation of the diagnosis from the impairment rating totally undermines its policy. The majority asserts that it would allow a diagnosis of CRPS “by a competent physician using medically-accepted criteria and on the basis of objective findings.” Ante, ¶ 27. I see nothing in its rationale that would impose any of these limits, and the broad statements are not supported by any citation to statute or decision. Under the majority’s rationale, a diagnosis of CRPS, based solely on subjective pain complaints and without any “objective findings” or “objective, observable criteria,” would be admissible, and if believed, would entitle claimant to an impairment rating for CRPS under the Guides.

 There has been a good deal of confusion about whether CRPS could also be rated under Chapter 18 (“Pain”), an idea that was refuted by an AMA-published article in 2006. R. Barth, Complex Regional Pain Syndrome (CRPS): Unratable Through the Pain Chapter, Guides Newsl. (Amer. Med. Assoc., Chicago, 111.), Nov./Dec. 2006. That same article went so far as to recommend rating CRPS under Chapter 14 (“Mental and Behavioral Disorders”), because “psychiatric factors could be used to predict the development of CRPS presentations with 91% •accuracy,” id. at 6 (citation omitted), and because of research revealing that “the majority of CRPS patients met criteria for a personality disorder.” Id. (citation omitted).

 As the majority states, this case involves CRPS I and not CRPS II.

I include this background because the majority relies upon a diagnosis under the IASP standards as fully complying with the Guides. Ante, ¶ 34.

 In the interchange noted in note 10, supra, the Vice-President of the AMA wrote, “The neurology approach [of Chapter 13], which enables the physician to rely on their own judgment, enables evaluators to incorporate the latest in evidence based medicine.” Letter from Michael Maves, Exec. V.P. of Amer. Med. Assoc., to Anthony Kirkpatrick, Dep’t of Anesthesiology, U. S. Fla. (Oct. 28, 2004), available at http://www.rsdfoundation.or^test/AMAreferenees.html.

 The claimant chose the impairment rating in Chapter 16, rather than that in Chapter 13, possibly for the reason that the Chapter 16 methodology produces a higher impairment percentage.

 The superior court had only the Kentucky Court of Appeals decision, which reached the same result based on the same reasoning.