         In the United States Court of Federal Claims
                                 OFFICE OF SPECIAL MASTERS
                                           No. 14-934V
                                     Filed: September 4, 2019

    * * * * * * * * * * * * *                  *    *
    MICHELLE DIXON-JONES,                           *       PUBLISHED
                                                    *
                 Petitioner,                        *
    v.                                              *       Dismissal; Influenza Vaccine; Chronic
                                                    *       Regional Pain Syndrome; Small Fiber
    SECRETARY OF HEALTH                             *       Neuropathy; Insufficient Proof of Causation
    AND HUMAN SERVICES,                             *
                                                    *
             Respondent.                            *
    * * * * * * * * * * * * *                  *    *

Amber D. Wilson, Maglio Christopher & Toale, Law Firm, Washington, DC, for Petitioner.
Sarah C. Duncan, U.S. Department of Justice, Washington, DC, for Respondent.

                               DECISION DENYING ENTITLEMENT1

Oler, Special Master:

        On October 3, 2014, Michelle Dixon-Jones (“Ms. Dixon-Jones” or “Petitioner”) filed a
petition pursuant to the National Vaccine Injury Compensation Program, 42 U.S.C. § 300aa-10.2
(“Vaccine Act” or “the Program”). In her petition Ms. Dixon-Jones alleges that the influenza
(“flu”) vaccination she received on October 6, 2011, caused her to suffer from right arm swelling,
extreme pain in the left ear, swelling of both hands, facial rash and shortness of breath, right eye
twitching, vertigo, nausea, short term memory loss, and worsening of her fibromyalgia.3 See
1
  This decision will be posted on the United States Court of Federal Claims’ website, in accordance with
the E-Government Act of 2002, 44 U.S.C. § 3501 (2012). This means the Decision will be available to
anyone with access to the internet. As provided in 42 U.S.C. § 300aa-12(d)(4)(B), however, the parties
may object to the decision’s inclusion of certain kinds of confidential information. To do so, each party
may, within 14 days, request redaction “of any information furnished by that party: (1) that is a trade secret
or commercial or financial in substance and is privileged or confidential; or (2) that includes medical files
or similar files, the disclosure of which would constitute a clearly unwarranted invasion of privacy.”
Vaccine Rule 18(b). Otherwise, this decision will be available to the public in its present form. Id.
2
 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755 (1986). Hereinafter,
for ease of citation, all “§” references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C.
§ 300aa (2012).
3
  Although Petitioner alleges worsening of fibromyalgia in the petition, Petitioner’s expert, Dr. Aradillas,
testified at hearing that Petitioner did not have fibromyalgia. Tr. at 107. As a result, I have not analyzed
whether Petitioner’s flu vaccination caused a significant aggravation of her fibromyalgia.

                                                        1
Petition (“Pet.”), ECF No. 1. Although no specific diagnosis was alleged in the petition,
Petitioner’s expert, Dr. Enrique Aradillas-López (“Dr. Aradillas”) diagnosed Ms. Dixon-Jones
with Chronic Regional Pain Syndrome (“CRPS”) and Small Fiber Neuropathy (“SFN”) following
the receipt of her flu vaccination on October 6, 2011. Ex. 37 at 2.

        Upon review of the evidence submitted in this case, I find that Petitioner has failed to carry
her burden showing that she is entitled to compensation under the Vaccine Act. Petitioner has
failed to show that she suffered from CRPS or SFN or that the flu vaccination she received caused
any of her symptoms. The petition is accordingly dismissed.

I. Procedural History

        Petitioner filed her petition on October 3, 2014.4 ECF No. 1. On June 9, 2015, Respondent
filed a Rule 4(c) Report, presenting his analysis of Petitioner’s claims and concluding that
entitlement should be denied in this case. ECF No. 18. Petitioner filed Dr. Aradillas’ expert report
on January 22, 2016 along with Dr. Aradillas’ curriculum vitae (“CV”). ECF No. 26, filed as
Exhibits (“Ex.”) 37, 38. Petitioner submitted medical literature on February 1, 2016. ECF Nos.
27-30. Respondent filed a responsive expert report of Dr. Phillip A. Low, as well as Dr. Low’s
CV, on April 22, 2016. ECF No. 33, filed as Exs. A, B. An entitlement hearing was scheduled
for January 29, 2018. ECF No. 42.

        At Petitioner’s request (ECF No. 50), I held a Rule 5 Status Conference on December 19,
2017, ultimately instructing the parties to ensure that their respective experts were prepared to
answer at hearing the questions I posed during the conference. ECF No. 51. On January 3, 2018,
I granted the parties an extension of time to file their respective pre-hearing submissions by
January 12, 2018. The parties filed their pre-hearing submissions on January 12, 2018, and
Petitioner timely filed medical literature (Exs. 74-116) on January 15, 2018. ECF Nos. 55-59. The
parties filed their joint pre-hearing submission on January 16, 2018. ECF No. 60.

        I issued a supplemental pre-hearing order on January 19, 2018, discussing a disciplinary
proceeding against one of Petitioner’s treating physicians, Dr. Walter E. Kozachuk. ECF No. 61.
The Maryland State Board of Physicians charged Dr. Kozachuk with “unprofessional conduct in
the practice of medicine and failing to meet the appropriate standards for the delivery of quality
medical care.” An Administrative Law Judge upheld the Board’s charges, finding that Dr.
Kozachuk met with several patients and wrote prescriptions for oxycodone, Xanax, and penicillin
in exchange for cash at Daniels Restaurant and Bar in Elkridge, Maryland and G.L. Shacks Grill
in Catonsville, Maryland. https://www.mbp.state.md.us/bpqapp/Orders/D3727904.256.PDF (last
visited August 27, 2019).5

        Petitioner filed an amended petition and medical records on January 19, 2018. ECF Nos.

4
 This case was initially assigned to now-retired Special Master Hastings (ECF No. 4), reassigned to Special
Master Corcoran on October 4, 2017 (ECF No. 45), and then reassigned to my docket on November 29,
2017 (ECF No. 48).
5
 The decision of the Administrative Law Judge was upheld by the Court of Appeals of Maryland. Kozachuk
v. Maryland State Board of Physicians (Dec. 13, 2017).

                                                    2
63-65. On January 22, 2018, I held a status conference, and the parties discussed the additional
records that Petitioner filed (i.e., medical literature (Exs. 74-116), amended petition, and medical
records (Exs. 117-127)). ECF No. 67. In light of the volume of records that were submitted by
Petitioner, Respondent requested that the hearing date be rescheduled; Petitioner had no objection.
Id. I rescheduled the entitlement hearing for July 23, 2018. ECF No. 69. Petitioner filed additional
medical records and a supplemental brief on June 22, 2018 (ECF No. 70, 71), and on July 2, 2018,
Petitioner filed additional medical records (ECF No. 72). Petitioner filed a supplemental affidavit
on July 6, 2018. ECF No. 73.

        I held an entitlement hearing on July 23, 2018 and ordered the parties to submit additional
documents to supplement the record. ECF No. 75. Respondent filed medical literature on July
31, 2018. ECF No. 76, filed as Ex. K. The Transcript of Proceedings (“Tr.”) was entered on
August 15, 2018. Petitioner filed medical literature on August 24, 2018. ECF No. 79. I held a
status conference on September 6, 2018, setting a deadline for the parties to submit their respective
post-hearing briefs. ECF No. 81. During the status conference, Petitioner’s counsel represented
that Petitioner will not pursue SFN as a claim in this case.6 Id. The parties filed their post-hearing
briefs on December 5 and 6, 2018. ECF No. 83, 84. In accordance with her counsel’s
representation during our status conference that she would not pursue a theory that the flu vaccine
caused SFN, Petitioner’s post-hearing brief did not mention SFN. Both sides indicated the record
was complete on February 22, 2019. ECF No. 86. Accordingly, this matter is now ripe for
adjudication.

II. Factual Background

    A. Petitioner’s Health Prior to the Allegedly Causal Vaccination

       Ms. Dixon-Jones’ pre-vaccination medical history is quite significant. In 1999, she was in
a motor vehicle accident and suffered a blunt head injury. Ex. 24 at 16, 19. She was subsequently
diagnosed with bilateral carpal tunnel syndrome and right brachial plexopathy. Id. She has
asthma, which has been treated with Advair since 2000. Id. at 3. She has hypothyroidism, which
has been treated with Synthroid since 2002. Id. In 2004, she had abdominal pain and evidence of
pancreatitis. Ex. 12 at 11. She was later diagnosed with pancreatitis in 2011. Id. at 10.

       On March 10, 1999, Ms. Dixon-Jones was admitted to the hospital due to a motor vehicle
accident that occurred the day before. Ex. 10 at 81. The location of her injuries was noted to be
the neck and right shoulder. Id.

        On January 4, 2000, she was seen at Howard County General Hospital for neck pain. Ex.
10 at 73. Her pain had been intermittent since March of 1999 and was noted to be worse. Id. She
was noted to have a headache. Id. The severity of her pain was described as radiating and
neurologic symptoms revealed “radiation to arm.” Id. Her pain was exacerbated by nothing and


6
  I specifically asked Ms. Wilson whether Petitioner still planned to pursue her SFN claim after Dr. Aradillas
testified at hearing that he had a low degree of confidence the flu vaccine caused Petitioner to develop SFN.
Based on Ms. Wilson’s representation, I have not analyzed the claim of SFN raised in the petition.


                                                      3
relieved by nothing. Id. She had decreased range of motion and muscle spasm. Id. at 74. Her
primary diagnoses were neck pain and radiculopathy. Id.

        Ms. Dixon-Jones had a right radial sensory nerve compression of the forearm on July 14,
2000, due to the pain she had in her right forearm along the dorsal radial. Ex. 15 at 16. She had a
right carpal tunnel release on April 19, 2001. Id. at 70. She had a left carpal tunnel release on
May 24, 2001. Id. at 46.

        Petitioner had a workman’s compensation injury involving her neck, back, left arm, and
left leg on August 21, 2002, when her chair collapsed while she was at work. Ex. 25 at 48. In
light of her injury, she “had multiple surgeries” and has “chronic pain.” Id.

       On October 15, 2003, Petitioner had an esophagogastroduodenoscopy7 with biopsy due to
recurrent reflux symptoms that included heartburn, bitter saliva, dysphagia, and chest discomfort.
Ex. 10 at 96. The diagnosis was reflux esophagitis that was moderate to severe. Id.

        On December 9, 2005, Ms. Dixon-Jones had an MRI of the thoracic spine. Ex. 123 at 49.
The MRI revealed “a moderate, broad-based, left paracentral soft disc herniation at T8-9.” Id. She
also had a MRI of the lumbosacral spine, which revealed a “[s]mall focal central soft disc
herniation slightly more to the right side, at L5-S1,” and the physician noted that such a “finding
has to be correlated clinically.” Id. at 50. “She reported tenderness to palpation of the muscles of
her neck, shoulders and arms. She had slight reduction in her strength….” Id.

        On June 15, 2006, Ms. Dixon-Jones had a nerve conduction study/electromyography. Ex.
18 at 29. The record acknowledges her “long history of upper extremity pain[, which she]
attributes the initial onset of the pain to a motor vehicle accident….Despite receiving bilateral
carpel tunnel syndrome surgery as well as neurolysis of her right radial nerve, she continued to
have pain.” Id. The record notes that her symptoms were “somewhat dormant[,] but have never
resolved.” Id. The pain in her arms increased since her diagnosis of pancreatitis the prior year.
Id.

       In 2006, she was diagnosed with lumbar disc degeneration with an abnormal MRI, and she
had radicular pain that was treated with epidural injections. Ex. 24 at 3.

        She had a gastroenterology consultation on May 15, 2008 due to abdominal pain. Ex. 19
at 7. She was taking an increased dosage of Advil for her back aches and had experienced, for the
past 10 to 12 days, severe left upper quadrant and epigastric pain. Id. Her pain felt like cramps
“with little radiation to the back” and was “accompanied with nausea but no vomiting or
heartburn.” Id. She denied dysphagia. Id. Physical examination revealed epigastric and left upper
quadrant tenderness. Id. at 8.

        On May 29, 2008, she had a follow up visit with Dr. Hanif for abdominal pain. The record
notes that the pain and burning in her left upper quadrant was “more prominent in the morning and

7
 An endoscopic examination of the esophagus, stomach, and duodenum. DORLAND’S ILLUSTRATED
MEDICAL DICTIONARY (32nd ed. 2012) at 648 (hereinafter “Dorland’s”).

                                                 4
persists through the daytime.” Ex. 19 at 5. Physical examination of her abdomen noted that it was
soft and non-tender. Id. at 6. Dr. Hanif’s impression was chronic gastritis and irritable bowel
syndrome (IBS). Id.

        On October 4, 2009, Ms. Dixon-Jones had an MRI of the thoracic spine, which revealed
“a degenerating disk in the midthoracic spine with mild posterior protrusion” and there were “some
osteoarthritic changes of the thoracic facets.” Ex. 125 at 209. Her medical record notes that
sometime in 2009, she had an H1N1 infection and encephalitis. Ex. 25 at 40. “Thereafter she
started with episodes of dizziness and recurrent syncope.” Id.

        Ms. Dixon-Jones saw Dr. Ogunsola on October 16, 2009 for mid and low back pain. Ex.
13 at 32. He reported that her pain was ongoing for several years and that it was worsening. Id.
She had occasional burning in the mid back area, which radiated laterally on the right side. Id.
She also had an achy sensation in her low back, which radiated into her right buttock and right
thigh. Id. The pain questionnaire showed that the location of her pain was in her back. Id. at 38.
The questionnaire included a diagram of the front-side and back-side of the human body, and the
back was shaded to reflect that the area of pain was in her back. Id. Her pain was described as
intermittent, worsening with prolonged sitting, cold temperature, certain weather, and emotional
stress. Id. at 39.

        Between March 24 and 31, 2010, Ms. Dixon-Jones was admitted at Northwest Hospital
Center due to abdominal pain that started two days earlier. Ex. 11 at 214-15. Onset of her
abdominal pain was abrupt, and it became progressively worse. Id. at 215. The record notes that
the course was constant and that she “mainly felt pain in the left flank area.” Id. Ms. Dixon-Jones
was also nauseated and vomiting and had mild epigastric pain. Id. Physical examination of her
abdomen revealed “presence of epigastric and left flank tenderness,” and she did not have “right
upper extremity tenderness.” Id. at 215-16. Two gallstones were found in her gallbladder and
uterine fibroids were found in her pelvis. Id. at 216. She had a consultation for her “persistent
nausea, abdominal and back pain for a month, which became worse.” Id. at 218. History of present
illness (“HPI”) noted that she was “in the usual state of her health until a month ago when she
started to have persistent nausea, abdominal and back pain.” Her abdominal pain was severe,
cramping in nature, and it radiated to her back and was accompanied by nausea. Id. Milk of
magnesia eased her constipation. Id. The discharge summary discusses the procedures that Ms.
Dixon-Jones underwent while admitted. See id. at 204; see also id. at 212-13 (Petitioner had an
operation to have her gallbladder removed).

   B. Petitioner’s Health after the Allegedly Causal Vaccination

      Ms. Dixon-Jones received an inactivated flu vaccine in her right deltoid on Thursday,
October 6, 2011, at her place of employment, Saint Agnes Hospital. Ex. 1.

        On October 12, 2011, Ms. Dixon-Jones saw Dr. Michael Mardiney, Jr. at Mardiney
Asthma, Allergy & Immunology Center (“AAIC”), reporting that she experienced pain and
swelling in her right arm about two and one half hours after her flu vaccination. She further
reported that the following Friday morning, around 3:30 AM, she experienced “extreme pain in
[her] left ear, swelling of both [of her] hands, facial rash[,] and shortness of breath.” Ex. 26 at 27.

                                                  5
Physical examination revealed that Ms. Dixon-Jones had clear skin, no hives, and no angioedema.
Id. Ms. Dixon-Jones reported tightness of her chest. Id. The injection site of her flu vaccination
was not visible. Id. It was the doctor’s impression that Ms. Dixon-Jones had an “adverse response
to [the] flu vaccine, manifested by angioedema, as well as bronchospasm[.]” Id. The doctor also
assessed Petitioner with Eustachian tube dysfunction and skin rash. Id. A Vaccine Adverse Event
Reporting System (“VAERS”) form was completed on October 14, 2011, detailing Ms. Dixon-
Jones’ onset of symptoms. Ex. 26 at 25. In addition to the symptoms reported to Dr. Mardiney
on October 12, 2011 and his impressions, the VAERS report states that Ms. Dixon-Jones had a
rash on her face on October 7, 2011, and that it was her first time receiving flu vaccine. Id.

        On October 23, 2011, Ms. Dixon-Jones visited Northwest Hospital Center for abdominal
pain, reporting that she had been experiencing such pain since receiving her flu vaccine. Ex. 11 at
8. Her complaint of epigastric pain was described as a moderate burning sensation, and she used
a laxative to induce bowel movement since she was unable to produce bowel movement for the
past seven days. Id. Although she mentioned experiencing nausea, she denied vomiting. Id. She
rated her chest pressure a three out of ten, and she was no longer experiencing shortness of breath.
Id. Her diagnoses were abdominal pain and chronic pancreatitis, and it was noted that she had a
follow-up visit with a gastroenterologist the following day. Id. at 10. CT scan revealed uterine
fibroid formation and “[p]artially collapsed right ovarian cyst with a small amount of free fluid.”
Id. at 11. She had “[s]table hemangioma in the right lobe of the liver.” Id. An x-ray of her
abdomen revealed “[n]o active disease in the chest[,] [t]he colon is at least mildly stool-filled[,
and] [n]o bowel obstruction or perforation.” Id.

        On October 26, 2011, Ms. Dixon-Jones saw Dr. Mardiney at AAIC who noted that “she
has been experiencing a ringing in the left ear intermittently and continues to experience
intermittent sharp pain in the left ear.” Ex. 26 at 26. The record further noted that she was also
experiencing vertigo-like symptoms. Id. Her evaluation “revealed some inflammation of the
pancreas and a cyst on the ovary” and her “pancreatic enzymes were elevated and her white cell
count was 16,000.” Id. Her physical examination was unremarkable. Id. The doctor’s
impressions were acute pancreatitis, which was improving, unspecified acute labyrinthitis,8 and
allergic diathesis9, which was noted to be related to her flu vaccine. Id.

        On November 1, 2011, Ms. Dixon-Jones saw a gastroenterologist with complaints of pain
in the right upper quadrant and epigastric region. Ex. 12 at 26. The pain was “burning in nature
and [went] into the left upper quadrant area and the back” beginning on October 23, 2011. Id. The
record noted that Ms. Dixon-Jones had a “history of similar pain for the past several years.” Id.
The record also noted that she “attributes the present pain to taking a flu vaccine at work.” Id.
The doctor noted that her pain “is of uncertain nature” and that “[t]here is no clinical or
biochemical evidence of pancreatitis [at that time], at least by [the doctor’s] review[ ] of the lab
work and/or imaging.” Id. at 27.


8
    Inflammation of the internal ear which may be accompanied by hearing loss or vertigo. Dorland’s at 995.
9
  Diathesis is a “condition of the body which makes the tissues react in special ways to certain extrinsic
stimuli and thus tends to make the person more than usually susceptible to certain diseases.” Dorland’s at
512.

                                                      6
        Ms. Dixon-Jones saw her allergist, Dr. Mardiney, again on November 2, 2011. Id. at 24.
She was still experiencing intermittent vertigo symptoms, which worsened when riding in a car.
Id. Her symptoms of left ear pain, which were noted to radiate into her left jaw, and her symptoms
of intermittent popping of her left and right ears still persisted. Id. Ms. Dixon-Jones also
complained of her right eye twitching for the past two weeks, which made her ability to focus
difficult. Id. She noted that her short-term memory was affected. Id. Her abdominal pain,
primarily in the right upper quadrant, persisted. Id. Dr. Mardiney no longer wanted Ms. Dixon-
Jones to take Singulair as he noted its possible contribution to her vertigo symptoms. Id. He also
noted his thought that Ms. Dixon-Jones’ vertigo symptoms may be due to crystal imbalance in her
inner ear. Id.

        On November 4, 2011, Ms. Dixon-Jones saw an ear, nose, and throat (“ENT”) doctor, Dr.
Mark S. Schneyer, with complaints of dizziness and left ear pain. Ex. 20 at 4. Her vertigo
intermittently occurred daily. Id. She also complained of her right eye twitching. Id. She
described how her dizziness and imbalance affected her while sitting and riding in a car. Id. She
also described the “piercing” pain in her left ear and how her hearing on the left side was worse as
compared to her right side. Id. Such pain was worse when touched anywhere around her ear. Id.
The record notes that she had “left ear pain since she had the allergic reaction to the flu shot” and
that “[s]he started Prednisone for a severe allergic reaction to her flu vaccine[.]” Id. Her piercing
pain “occurred intermittently every few days up to last Friday. Since then she has not had any
piercing ear pain….She thinks the pain just dissipates on its own.” Id. Petitioner also reported no
headaches. Id. The doctor informed Ms. Dixon-Jones that her hearing was “completely normal”
and he ordered electronystagmogrophy10 and videonystagmography testing. Id at 5.

        Ms. Dixon-Jones had a GI follow up visit on November 8, 2011, and the record notes that
her “endoscopic ultrasound examination showed a normal-appearing pancreas,” the “pancreatic
duct and the bile duct were not dilated.” Ex. 12 at 37. Her HIDA scan revealed a normal common
bile duct. Id. The doctor believed that she did not have evidence of chronic pancreatitis or acute
pancreatitis, and “it appears that she may not have sphincter of Oddi dysfunction at this time.” Id.
The doctor further noted that “[b]efore proceeding to further invasive testing, [the doctor]
believe[s] other etiologies of pain need to be looked into. Since [she] has thoracolumbar disease
and a burning band-like pain which goes around her upper abdomen and back, her disc disease
needs to be excluded.” Id.

       On November 15, 2011, Ms. Dixon-Jones visited Barenburg Eye Associates. Ex. 2 at 13.
The purpose of her visit was due to dizziness, memory loss, and blurred vision. Id. The record
notes that she received her flu vaccination on October 6, 2011, that she was in the process of
undergoing tests and was temporarily disabled. Id.

       Ms. Dixon-Jones had a laparoscopic hysterectomy on November 17, 2011. Ex. 8 at 107.
On November 21, 2011, Ms. Dixon-Jones consulted with Dr. David J. Wang at St. Agnes Hospital
for symptoms of palpitations and lightheadedness. Id. at 104. This consultation occurred after her
laparoscopic hysterectomy, recurrent abdominal pain, and bleeding from her umbilicus. Id. Ms.

10
  Electornystagmogrophy is the “recording of changes in the corneoretinal potential due to eye movements,
providing objective documentation of induced and spontaneous nystagmus.” Dorland’s at 602.

                                                   7
Dixon-Jones woke up with symptoms of lightheadedness, diaphoresis, and palpitations. Id. The
record notes that Ms. Dixon-Jones had a diagnosis of primary pulmonary hypertension, recurrent
supraventricular tachycardia, non-sustained ventricular tachycardia, and hypertension. Id. Dr.
Wang reported that “[t]he exact etiology of the supraventricular tachycardia remains unclear […]
but it is clear that is a reentrant tachycardia (reentrant atrial tachycardia versus atrioventricular
nodal reentry tachycardia likely).” Id. at 105.

        On November 19, 2011, Ms. Dixon-Jones was seen at Howard County General Hospital
for bleeding at the surgery site. Ex. 10 at 28.

        Ms. Dixon-Jones saw Dr. Schneyer again on November 20, 2011 for dizziness and
imbalance. Ex. 20 at 2. This was a follow up visit after her electronystagmogram (“ENG”), which
was normal. Id. The record notes that her symptoms have not improved, and Dr. Schneyer
explained to her that he is unsure as to the cause of her symptoms and is unable to explain why her
symptoms occurred after her flu vaccination. Id. The doctor noted that her inner ear appears to
be functioning as normal, with a normal ENG and audiogram. Id. He informed Ms. Dixon-Jones
that she should have her primary care physician set up an appointment with a neurologist. Id.

        Ms. Dixon-Jones saw Dr. Mardiney on December 7, 2011. Ex. 26 at 22. At such time, she
was “having some radiculopathy and [planned] to take her most recent MRI to her pain
management specialist and will likely be referred to a neurosurgeon.” Id. Her allergies were
controlled, with the exception of experiencing some rhinorrhea and voice degradation, and she was
prescribed Claritin for her rhinorrhea. Id.

        On December 9, 2011, she saw Dr. Ogunsola for low back pain and abdominal pain. Ex.
16 at 23. She “complains of low back pain, radiating to right buttock, radiating to left buttock,
radiating to right knee, and radiating to left knee. Associated symptoms include stiffness.” Id. She
described her pain as burning, aching, and constant. Id. She was also experiencing abdominal
pain, including nausea and constipation, localized to her right and left upper quadrant. Id. She
described her pain as sharp, constant, and unchanged, and the pain was worse when she walked.
Id. The doctor notes that she “presents today for a follow-up assessment of chronic pain” and that
she reports “pain in the bilateral low back and bilateral radiculopathy. This began >1 year ago”
and she “describes the pain as worsening, constant, and burning….The pain is made worse by
standing and sitting.” Id. at 24. Her pain is improved with medicine and nerve block injections.
Id.

         On December 19, 2011, Ms. Dixon-Jones saw a neurologist, Dr. Michael S. Sellman, for
evaluation of her memory loss and vertigo. Ex. 18 at 15. The record described her prior medical
history and symptoms, including her allergic reaction to the flu shot, dizziness, issues with her
vision, hypertension, bleeding difficulties, and baseline fibromyalgia pain in her arms. Id. The
record also noted that she did not completely heal from her hysterectomy. Id. Ms. Dixon-Jones
did not exhibit any symptoms of memory loss and vertigo during evaluation. Id. at 16. Dr. Sellman
noted that “she did not think she had memory problems, dizziness, or blurred vision today[,]” and
described her as being “awake, alert, and oriented.” Id. Ms. Dixon-Jones was able to read and
speak fluently, with no signs of dysarthria. Id. She was also able to recall three out of three words
in a three-minute time period. Id. Dr. Sellman noted that “it [was] speculative what event occurred

                                                 8
[in the] fall to cause Mrs. Dixon-Jones to intermittently have problems with memory loss as well
as vision and balance.” Id. Dr. Sellman noted that she had normal cranial nerve function, but she
had difficulties with tandem walking. Id. The doctor ordered an MRI, a visual and auditory evoked
response test, vestibular physical therapy, and cognitive rehabilitation. Id.

        Ms. Dixon-Jones complained of lower back pain on January 9, 2012, which radiated to her
right and left buttock and her right and left knee. Ex. 16 at 29. She described her pain as “burning,
aching, and constant.” Id. Her abdominal pain, including symptoms of nausea and constipation,
was localized to her right and left upper quadrant, and described as “sharp, constant, and
unchanged.” Id. She was status post LESI (lumbar epidural steroid injection), which improved
her low blood pressure, “but she continues to have generalized muscle weakness and fatigue and
dizziness since her flu shot on 10/06/2011.” Id. The record notes her appointment with a
neurologist. Id. Her assessment notes that her pain is improving (by way of nerve block
injections). Id. at 30. Her multi-disciplinary pain assessment notes that her pain screening and
pain score are both 4 out of 10. Id. at 31. It also notes that her pain, described as burning and
sharp, is located in her mid-back, which radiates around her abdomen, as well as bilaterally in her
feet and legs. Id. Physical examination revealed “Facial puffiness” and her abdomen was “non[-
]tender to palpation”. Id. She had normal heel-toe gait pattern bilaterally. Id. Her face puffiness
likely was due to steroids. Id. at 32. The record also notes her spondylosis, lumbago, cervical
radiculopathy, and facet syndrome-lumbar were unchanged. Id.

        Ms. Dixon-Jones saw Dr. Sellman again on January 19, 2012 for a re-evaluation of her
memory loss and vertigo. Id. at 9. The notes indicate that she was dizzy while in the waiting
room. Id. She informed the doctor about her appointment at Johns Hopkins rather than St. Agnes
Hospital, due to a medical malpractice lawsuit against the gynecologist who performed her
hysterectomy at St. Agnes Hospital. Id. She also informed the doctor of her history of
posttraumatic stress disorder (PTSD)11, which she stated developed in the year 2005 after an
epidural injection – she blamed her memory loss for not reporting her posttraumatic stress disorder
at her initial evaluation. Id. The doctor described Ms. Dixon-Jones as “awake, alert, [and]
responsive[.]” Id. The doctor had her stand up and walk, which she was able to do; however, she
was unable to perform tandem walking. Id. She was able to recall two out of three words in a
one-minute time period, and one out of three words in a three minute time period. Id.

        On January 21, 2012, Ms. Dixon-Jones saw her allergist, Dr. Mardiney, who noted that her
          12
allergy and asthma were stable; however, she continues to experience issues with strength,
balance, fibromyalgia, memory loss, dizziness, and blurred vision. Ex. 26 at 21. The doctor noted
that “[h]er easy fatigability is suggestive of possible adrenal dysfunction[,]” and that he wants Ms.
Dixon-Jones to be reviewed by an endocrinologist. Id.

       January 23, 2012 was Ms. Dixon-Jones’ first visit to Johns Hopkins Hospital Department
of Physical Medicine and Rehabilitation (“Johns Hopkins Rehabilitation”). Ex. 27 at 70. She


11
  But see the impression of Dr. Jody Whitehouse on January 22, 2015: “I did not detect any significant
psychopathology including Post-Traumatic Stress Disorder.” Ex. 32 at 4.
12
     Ms. Dixon-Jones had an allergic reaction Thursday, January 19, 2012 while at a hair salon. Ex. 26 at 21.

                                                       9
complained of memory impairment, anomia, limitations on walking, dizziness while driving, and
weakness. Id. at 71, 74.

       On February 2, 2012, she went to Northwest Hospital Center for a right lower extremity
venous Doppler, and the clinical indication notes pain and swelling. Ex. 11 at 48. There was “no
evidence of right lower extremity DVT.” Id.

        On February 6, 2012, she saw Dr. Ogunsola for a follow up visit. Ex. 16 at 34. HPI notes
her complaints of low back pain that radiates to her right and left buttocks as well as her right and
left knees. Id. It also notes her history of abdominal pain. Id. Ms. Dixon-Jones was status post
LESI, which helped her low blood pressure; however, she “continues to have generalized muscle
weakness and fatigue and dizziness since her flu shot on 10/06/2011.” Id. Pain assessment notes
that she is following up for her chronic pain, and that she has had “[w]orsening weakness and
fatigue since October” and “[b]urning sensation in the mid back and abdomen.” Id. at 35. Multi-
disciplinary pain assessment notes that she is currently in pain, the location being bilateral feet,
and mid back which radiates around the abdomen. Id. at 36. Duration of pain is greater than six
months and the pain is characterized as burning and sharp. Id. Physical examination revealed
facial puffiness and her abdomen was “non[-]tender to palpation.” Id. Her gait was slow and
calculated. Id. She had palpation-spinal tenderness, described as mild, in her mid-lower back. Id.
at 36. Range of motion for forward flexion was 20 degrees and 10 degrees for hyperextension.
Id. Her ability to toe walk, heel walk, and raise her legs straight out from a sitting position was
normal. Id.

        Ms. Dixon-Jones saw her neurologist, Dr. Sellman, on February 17, 2012 with multiple
complaints, including short-term and long-term memory loss as well as “staring for no apparent
reason.” Ex. 18 at 7. At this time, she attended memory loss therapy at Johns Hopkins and was
also seeing a psychologist at Johns Hopkins. Id. It was noted that she had a neuropsychological
test, but there was no documentation of the results – Dr. Sellman requested that she bring the
results at her next visit so that he could review the results. Id. Her examination revealed Ms.
Dixon-Jones to be awake and alert; however, she had difficulties with calculations. Id. The doctor
noted that she was able to recall the year, place, and person, as well as three out of three words in
both a one-minute and three-minute time period. Id. The doctor also noted a normal cranial nerve
function, and that Ms. Dixon-Jones was able to walk slowly. Id. Ms. Dixon-Jones informed the
doctor that “she was having diffuse pain throughout her entire body from fibromyalgia.” Id. An
EEG was reported as normal, and no seizures were recorded. Id. at 18.

        Ms. Dixon-Jones saw Dr. Sellman on March 14, 2012. Id. at 5. She revealed that she was
in “a great deal of pain[,]” and that “her pain management doctor is not able to help her.” Id. At
this time, the memory treatments at John Hopkins are noted to be terminated as her therapist
informed her that treatment would not be effective due to the amount of pain she was experiencing.
Id. Dr. Sellman noted that he still did not have records of Ms. Dixon-Jones’ neuropsychological
testing, although she informed him that someone in the office confirmed that he received such
records. Id. She informed him that she would bring him physical copies of the records. Id. Upon
examination, the doctor noted that Ms. Dixon-Jones “appeared situationally depressed[,] appeared
uncomfortable[,] and complained bitterly of pain due to her fibromyalgia.” Id. The record notes
that Dr. Sellman referred Ms. Dixon-Jones to Johns Hopkins Bayview Hospital’s Memory and

                                                 10
Alzheimer’s Treatment Center as it was his opinion that such treatment center would be the best
place to treat her symptoms. Id.

        On April 18, 2012, Ms. Dixon-Jones went to Johns Hopkins Rehabilitation. She informed
her therapist, Dr. Kortte, that she had been experiencing cognitive and emotional difficulties, and
attributed such difficulties to her adverse reaction to the flu shot. Ex. 27 at 32. The goal of her
therapy sessions was to “improv[e] her pain and fatigue management and maximize[e] her
cognitive functioning, facilitating her emotional adjustment.” Id. During her therapy session, Ms.
Dixon-Jones mentioned her issues with sleeping and pain, and “verbalize[d] the synergistic
relationship between her sleep and pain difficulties and how these also affect and are influenced
by her frustration levels.” Id. The notes inidicate she experienced adverse reactions to Ambien
and had discontinued it, but was currently taking Lunesta that did not provide much relief. Id. She
was also taking Zonegran to control her pain, but she mentioned that “[s]he does not find that
anything attenuates her pain.” Id. She described her pain as a constant burning sensation that
migrates to different areas of her body as well as a cold sensation in her left hand. Id. Her diagnosis
was “late effect of adverse effect of drug, medicinal, or biological substance.” Id. at 33.

         On April 26, 2012, Ms. Dixon-Jones saw Dr. Sellman who indicated that she was scheduled
to undergo neuropsychological testing by Dr. Newman. Ex. 18 at 3. She informed the doctor of
her wishes to see a pain management specialist as she “feels that she has reflex sympathetic
dystrophy.”13 Id. She mentioned having minor issues with her arms, which were being controlled
with Lyrica as prescribed by her pain management specialist, Dr. Ogunsola, whom she expressed
she no longer wanted to visit. Id. Dr. Sellman informed Ms. Dixon-Jones that he has “no
experience in her specific allegations that she is having problems as a complication of the flu
shot[,]” and he requested that she “continue endeavoring to find a physician with experience in
[that] disorder.” Id. at 3-4. In regard to symptoms of memory loss, Ms. Dixon-Jones agreed to
visit the doctor again after neuropsychological testing. Id. at 4.

        On April 30, 2012, Petitioner visited the Johns Hopkins Rehabilitation. She saw Dr.
Michelle Kramer (Psy.D.) During this visit, Dr. Kramer noted concerns “regarding [Ms. Dixon-
Jones’] continued belief that she will find a neurologist who will diagnos[e] her properly, find a
treatment and significantly decrease her pain[.]” Ex. 27 at 29. Ms. Dixon-Jones mentioned her
prior experiences with chronic pain in the past and her ability to manage such pain, but the current
pain she was experiencing “is ‘different’ and she described the intensity as unbearable, intolerable
and the cost of misery too high.” Id at 30. She further mentioned that “[s]he has become more
independent from her husband over the last few months and she attributes [that] to improved
physical functioning after surgical recovery and improved cognition after discontinuing opioid
use.” Id. Her diagnosis was “late effect of adverse effect of drug, medicinal, or biological
substance.” Id.

       On May 7, 2012, she reported that her muscle pain, weakness, fatigue, and dizziness were
unchanged and also reported “tingling and piercing sensation in random areas.” Ex. 16 at 49. She
was still having problems with her memory loss. Id. The assessment notes that her physical
therapy had been unhelpful. Id. at 50.

13
     CRPS was formally known as reflex sympathetic dystrophy. See Ex. C at 1.

                                                   11
        On June 14, 2012, Ms. Dixon-Jones saw a neurologist, Dr. Walter E. Kozachuk, with
several complaints, including headaches, cognitive dysfunction with decreased recent memory,
dysphasia with word finding difficulty and word substitution, disequilibrium and intermittent
vertigo, generalized myalgias in the upper extremities, pain and paresthesias of the upper
extremities, fatigue along with decreased physical endurance and insomnia, and loss of function
with inability to perform her prior job in nursing. Ex. 24 at 1.

        Dr. Kozachuk noted Ms. Dixon-Jones’ post-vaccination medical history and symptoms in
great detail. The record noted that she had bilateral arm tremor while sleeping and did not
experience such tremor while awake. Ex. 24 at 2. She informed the neurologist that she was
terminated from her place of employment due to her inability to perform some of her tasks. Id.
She also informed the neurologist of her rehabilitation and vestibular training, which she stated
was not effective. Id. She also complained of chronic generalized headaches since her flu
vaccination. Id. Her examination revealed mild acute distress along with pain and anxiety. Id. at
3. Her speech, which was fluent, and her free gait, which was normal, were both noted as slow.
Id. Her “tandem and single leg standing were mildly impaired[, her] Romberg sign and cerebellar
exam was normal[, her] [c]ranial nerves were normal with no nystagmus or VI nerve palsy.” Id.
She had normal cervical range of motion with no pain on palpation, and there was no pain on
palpation of her thoracic or lumbar spine. Id. Her “[s]ensory exam in the hands to touch [was]
normal” and “Tinel’s sign was normal in the elbow and wrists.” Id. She had no pain palpation in
her trapezius muscles, and the range of motion in her shoulders was normal. Id. “Motor exam of
the arms was normal.” Id. Dr. Kozachuk’s impression mostly mirrored Ms. Dixon-Jones’ list of
complaints, with the addition of “[p]ost vaccination symptoms of acute anaphylaxis with chronic
symptoms of headache[,] [a]bnormal neurological exam with increased reflexes in the legs with
spread and body myoclonic jerks[,] patient’s physical symptoms of chronic pain and cognitive
dysfunction show direct causation to the accident of 10-6-11[, and] [t]he patient is totally and
temporarily disabled.” Id. at 3-4. (Emphasis omitted).

       Ms. Dixon-Jones had a follow up visit with Dr. Kozachuk on July 25, 2012. Ex. 24 at 5.
The doctor reviewed records from Johns Hopkins University and found that “there was no
diagnosis for the etiology of her dysequilibrium.” Id. Examination of Ms. Dixon-Jones revealed
“no change in the physical exam and no new focal symptoms.” Id. Dr. Kozachuk scheduled an
electromyography (“EMG”) of her upper extremities to rule out gammopathy or sensory
neuropathy. Id. at 8.

         Ms. Dixon-Jones had an EMG on August 22, 2012. Ex. 7 at 2. The results were normal,
and it was reported that “[e]lectrodiagnostically there was no evidence for a large fiber neuropathy,
a left [upper extremity] entrapment neuropathy[,] or for a left cervical radiculopathy at [that] time.”
Id. at 3. Such results were acknowledged by Dr. Kozachuk during Ms. Dixon-Jones’ follow up
visit with him on September 13, 2012. Ex. 24 at 9. At that visit, Ms. Dixon-Jones reported
“recurrence of left facial rash and pruritis.” Id. She stated that she experienced an increase of pain
in her extremities and trunk. Id. She also stated that she had burning dysesthesias of her arms,
with sensation being greater in her left arm as compared to her right arm. Id. She reported an
increase in severity of her disequilibrium. Id. The record mentioned a new onset of sleep
difficulty, specifically moderate insomnia and her not feeling refreshed after she sleeps. Id. at 10.

                                                  12
The doctor noted that she is undergoing pain management treatment for her fibromyalgia. Id.
Examination of Ms. Dixon-Jones revealed “no change in the physical exam and no new focal
symptoms.” Id.

        On September 17, 2012, Ms. Dixon-Jones was seen at Howard County General Hospital
for a lumbar puncture and to rule out Alzheimer’s disease. Ex. 10 at 21.

        On September 28, 2012, Ms. Dixon-Jones had a quantitative electroencephalography (“Q-
EEG”) or brain mapping. Ex. 26 at 50. The unusual features of this testing revealed that Petitioner
showed “very significant slowing in the posterior area of the cortex, parietal to occipital lobes …
slowing in the left and right temporal lobes … slowing in the frontal cortex … in what appears to
be a coup-contracoup injury”14 as well as “damage in cortical function … affecting ability to think
in abstract concepts or connections.” Id.

        Ms. Dixon-Jones went to Nasseri Clinic of Arthritic & Rheumatic Diseases (“Arthritic &
Rheumatic Clinic”) on February 14, 2013 in order to rule out polymyalgia rheumatica (“PMR”).
Ex. 3 at 6. The record noted that she was a patient of such clinic who had not been seen in several
years. Id. The record provided a brief overview of Ms. Dixon-Jones’ medical history, including
her diagnosis of fibromyalgia syndrome in 2006 and her reported diagnosis of posterior reversible
encephalopathy syndrome (“PRES”) following her flu vaccination. Id. Her current complaints
were “intermittent burning pain in her bilateral shoulders, thighs, or knees, also increased fatigue.”
Id. Ms. Dixon-Jones mentioned that she has a history of a rash located on her right cheek, which
was not present during the time of her visit, but she was able to provide pictures. Id. It appears
the rash would resolve on its own within one to two weeks. Id. She further mentioned her history
of having headaches, describing it as diffuse, and associating her headaches with her symptoms of
dizziness. Id. She denied that numbness and tingling were associated with her headaches. Id.

        The record noted that Ms. Dixon-Jones was not currently on medication for her
fibromyalgia, but she would take Dilaudid, prescribed by pain management, for breakthrough pain.
Id. She was assessed with having pain in her joints located at multiple sites. Id. at 7. The doctor
found “little subjective or objective evidence of inflammatory arthritis or specifically PMR[,]” and
believed that “it [was] likely her symptoms which also include numerous trigger points on upper
and lower extremities are a flare of her previously diagnosed fibromyalgia.” Nonetheless, the
doctor planned to conduct extensive laboratory testing in order to rule out the possibility that her
diffuse arthralgias and myalgias were caused by inflammation or infections. Id. The doctor also
planned to look for any secondary causes for her fatigue. Id.

        On February 18, 2013, Ms. Dixon-Jones had a MRI of the thoracic spine, which revealed
“degenerative disk and small central disk herniation T8-T9.” Ex. 13 at 19. In comparison to her
October 4, 2009 examination, “there are mild degenerative changes of the cervical and thoracic
disks. There is narrowing at the T8-T9 level, with a central disk protrusion. This appears to be
slightly more prominent than the previous study.” Id.


14
  A coup is defined as “a blow or attack.” Dorland’s at 426. A contrecoup is an “injury resulting from a
blow on another site, especially of the brain….” Id. at 410.

                                                  13
      Ms. Dixon-Jones saw an optometrist, Dr. Joshua Gordon, on February 19, 2013. Ex. 2 at
11. A diagnosis of PRES was noted in her health history as well as a diagnosis of fibromyalgia.
Id.

       On November 19, 2013, Ms. Dixon-Jones visited Dr. Patrick Okolo and was diagnosed
with gastrointestinal dysmotility. Ex. 27 at 2. The comments section of this record notes “brain
swelling after flu vaccine.” Id. at 13.

       On March 3, 2013, Petitioner went to the ED complaining of syncopal episode associated
with seizures. Ex. 10 at 9. The summary of her care at the ED stated, “Return for recurrent
episodes of passing out. You are dehydrated.” Id. at 15.

         On March 20, 2013, Ms. Dixon-Jones followed up with Dr. Nasseri at the Arthritic &
Rheumatic Clinic, and she had complaints of “shoulder pain and burning sensation in her bilateral
thighs.” Ex. 3 at 1. She also stated that she has headaches in the occipital area on a daily basis.
Id. The doctor noted that she has “a history of fibromyalgia syndrome, and when seen [on February
14, 2013], extensive laboratory testing was done to rule out the possibility of an inflammatory
arthritis.” Id. The doctor, after a review of her laboratory testing results, noted that her results
were normal “with the exception of a very mildly elevated high-sensitivity CRP of 8.” Id. The
doctor’s assessment was joint pain located in multiple sites. The doctor “[did] not believe that she
has a PMR or temporal arteritis” as it was unknown in patients under the age of fifty and Ms.
Dixon-Jones, at that time, was forty-five years old. Id. at 4. In regard to the laboratory testing,
there was “no evidence of an inflammatory arthritis” and the doctor believed that her symptoms
“are an exacerbation of her previously diagnosed fibromyalgia […] [The doctor] believe[s] that
her fibromyalgia is very severe.” Id. The doctor notes that Ms. Dixon-Jones “has previously failed
Lyrica and Cymbalta and has been advised by her neurologist and pain management specialist not
to take Savella.” Id.

        Ms. Dixon-Jones had a whole-body scan, ordered by Dr. Nasseri, on March 28, 2013 to
evaluate for reflex sympathetic dystrophy (CRPS). Ex. 11 at 41. Her bone scan findings provide
the following: “Flow images of pelvis and thigh appear normal. Immediate blood pool images of
lumbar spine, pelvis, thigh, knees and feet are obtained which are also unremarkable….Mild
degenerative change bilateral shoulders and first MTP joint right foot. Uptake in rest of the
skeleton is unremarkable.” Id. In conclusion, she had “[n]o bone metastases” and “[n]o
scintigraphic evidence of reflex sympathetic dystrophy.” Id.

        On April 12, 2013, Ms. Dixon-Jones had a gastroenterology consultation due to having a
two- to three-day history of upper abdominal pain, nausea, and periodic vomiting. Ex. 10 at 192.
She “describes the pain to be cramping in nature and accompanied with nausea and feverish
feeling.” Id. She also had constipation. Id. Review of symptoms indicated that she has had
headaches, a dizziness spell with seizure, and chronic pelvic pain. Id. at 193. Radiology revealed
no evidence of pancreatitis, hepatic hemangiomas were noted; her abdominal ultrasound was
normal. In his discharge report, Dr. Charles Moore noted: “Likely this patient has underlying scar
tissue as a potential course of the pain along with the possibility of there being some contributory
chronic back pain.” Ex. 11 at 170.



                                                14
        On May 3, 2013, Ms. Dixon-Jones complained of low back pain that radiates to her right
buttock and left buttock, as well as her left and right knees. Ex. 16 at 91. She also reports
abdominal pain, and generalized burning sensation in her shoulder, hip, knee, and feet. Id. “She
reports today that she has a Sphincter of Oddi dysfunction.” Id.; see Ex. 12 at 37 (visit on
November 8, 2011, which states “patient also underwent a HIDA scan whereby the study was done
to look for sphincter of Oddi dysfunction. The study revealed normal common bile duct”).

        Ms. Dixon-Jones saw Dr. Eric H. Williams on June 17, 2013, “with a complaint of bilateral
upper extremity pain and weakness that has been present for several years.” Ex. 127 at 32. She
reported pain in her neck and shoulders, numbness and tingling in her hands, and burning, searing,
and prickling pain in the backs of her hands. Id. She also reported fatigue and weakness. Id. She
informed Dr. Williams of her EMG results, which revealed she had thoracic outlet syndrome. Id.
“She presents today to try to identify any potential causes of her persistent upper extremity arm
weakness and pain.” Id. Right and left palpation revealed “tender scalene anticus” and right and
left Tinel exam revealed “tinel over scalene anticus and roos maneuver positive” as well as “tinel
over radial tunnel and tenderness over radial tunnel.” Id. Right and left vascular revealed “normal
color and temperature and no varicosities and radial pulse 3/4.” Id. at 33. Dr. Williams assessed
her with pain in limb and the doctor ordered an MRI of the brachial plexus and referred her to
neurology. Id.

        On July 3, 2013, Ms. Dixon-Jones had a gastroenterology follow up visit, which occurred
post-endoscopy and colonoscopy. Ex. 12 at 52. The medical record notes that she “was seen in
our office on June 5, 2013 for these symptoms and it was [the doctor’s] assessment that [she] was
having accentuation of her reflux from unknown factors and also accentuation of her IBS because
of the opiates that she has been taking for her pain.” Id. The doctor stated that his impression was
that her “chronic pain may be related to IBS with constipation accentuated by opiate dependence,
but gastroparesis may be playing a role as well and that there was no evidence of chronic
pancreatitis at the present time.” Id. at 53.

       Ms. Dixon-Jones had surgery on July 10, 2013. Ex. 5 at 64. The procedure performed is
noted as “[d]iagnostic laparoscopy, lysis of adhesions, bilateral salpingo-oophorectomy,
fulguration of stage I endometriosis.” Id. Her postoperative diagnosis was “[s]tage I
endometriosis, intra-abdominal adhesions.” Id.

        Ms. Dixon-Jones saw Dr. Christopher L. Fortham on January 7, 2014 due to bilateral
shoulder pain and stiffness that began in the summer of 2013. Ex. 17 at 13. Physical examination
revealed that, generally, her skin and subcutaneous tissues of both arms were normal. Id.
“Peripheral pulses are palpable, bounding, and symmetric at the wrists. Both shoulders appear
normal.” Id. at 13. She was unable to touch her thoracic spine, and she had “reasonable cuff
strength with resisted abduction and resisted external rotation – no lag signs.” Id. Her radial artery
was palpable. Id. “She has sensibility in the axillary distribution as well as in her fingers.” Id.

       The doctor also examined Ms. Dixon-Jones’ hands, which revealed “no discernible
misalignment, asymmetry, crepitation, tenderness, masses, effusions or prominence.” Id. Her
range of motion “is satisfactory without pain, crepitation or contracture.” Id. All of her joints



                                                 15
were stable, and her muscle strength and tone were satisfactory. Id. “In summary, [she] has severe
bilateral shoulder adhesive capsulitis.” Id. at 14.

        On February 14, 2014, Ms. Dixon-Jones had surgery (right shoulder scope capsular release)
due to right shoulder pain. Ex. 15 at 89. Her postoperative diagnosis was adhesive capsulitis. Id.

        On July 21, 2014, Ms. Dixon-Jones had a follow up gastroenterology visit. Ex. 14 at 7.
The medical record notes that she had symptoms of chronic nausea with known vestibular
dysfunction, GERD and intermittent left upper quadrant abdominal pain. Id. The record also notes
that “she is recovering from right shoulder surgery” on June 20, 2014 (“R shoulder arthroscopic
debridement, lysis of adhesions and decompression with regular physical therapy”). Id. She
denied having epigastric pain at this time. Id. Doctor’s assessment and plan notes that her “nausea
is likely multifactorial with vestibular dysfunction and chronic opiate use being the most likely
etiologies.” Id. at 12. “Chronic narcotic use can certainly cause delays in the GI tract…which can
exacerbate symptoms of nausea and bloating.” Id. “A trial of neuromodulators may decrease her
narcotic requirement as her pain is partially neuropathic in nature (known disc disease,
fibromyalgia, etc).” Id. The doctor believes that her nausea is caused by “a combination of
vestibular dysfunction and narcotic use.” Id. at 13.

        Ms. Dixon-Jones saw Dr. Williams on August 21, 2014 to follow up with her complaints
of skin sensation disturbance, hand joint pain, and pain in limb. Ex. 127 at 15. Her physical
examination results are similar to her exam on June 17, 2013 (id. at 32), with the addition of having
a frozen shoulder that would not lift beyond 45 degrees. Id. at 18. Dr. Williams assessed her with
pain in limb and radial neuropathy. Id. at 19.

        On October 13, 2014, Ms. Dixon-Jones saw Dr. Aradillas due to experiencing “terrible
pain.” Ex. 23 at 6. Physical examination revealed “right shoulder is in spasm, left shoulder is
dropped, obvious livedo reticularis worse at the legs than the arms....” Id. at 6. She was positive
for the following:

       Roos’ and Wright’s brachial plexus abduction maneuvers[;] Tinel’s signs at the
       supraclavicular fossa, the C2 point and the distal clavicle as well as in the
       neurovascular bundle and the Arcade of Froshe on the left arm and right arm[;] joint
       pain, and deep sensitization and [] allodynia, mechano more than thermos and the
       dynamic is worse.

Id. at 7. She was positive for the following pain processing: “spread and loss of surround
inhibition[;] hyperpathia and [] hyperalgesia. Upon sensory exam there was a decreased sensory
on a lateral cord distribution bilaterally and a clear glove distribution of loss of pain and
temperature up to the level of the mid forearm bilaterally.” Id. Her right arm was swollen
throughout and evident at the hand and forearm, and she had purplish discoloration in both of her
hands. Id. There was “[n]o local temperature difference between left and right” and there was
“local diaphoresis at both hands right worse than left.” Id. Dr. Aradillas states that she had “clear
decrease in sensation small fiber modalities in a glove and stocking distribution,” which is not a
consequence of her long term depression, but rather from a neuropathic process. Id. at 8. She had
abnormal triple response of Lois. Id. Dr. Aradillas assessed Ms. Dixon-Jones with CRPS, SFN,

                                                 16
and noninfectious acute disseminated encephalomyelitis (“ADEM”). Id. His plan was for her to
have a skin biopsy and blood work for possible SFN. Id. Dr. Aradillas stated that she was a good
candidate for ketamine infusions. Id.

        On February 11, 2015, Ms. Dixon-Jones had a consultation at Mercy Health Services with
Dr. David Maine. Ex. 33 at 3. She complained of mid and low back pain, which started in her
mid back and radiated to her low back. Id. Occasionally, the pain radiated down her right leg, but
she reported that it did so infrequently. Id. The record notes that she “has been diagnosed with
posterior reversible encephalopathy syndrome, as well as a brain injury to the occipital, right
frontal and corpus callosum.” Id. The record also notes her “history of brain paresthesia, cyclic
vomiting syndrome, and a diagnosis of complex regional pain syndrome.” Id. She goes to
Pennsylvania for ketamine infusions. Id. “She has also been diagnosed with vertigo, severe
fibromyalgia, chronic fatigue syndrome, as well as a brachial plexus entrapment syndrome in the
setting of a previous motor vehicle accident.” Id. She rates her pain a six out of ten. Id.

       Review of symptoms states that she reports weight gain, shortness of breath, irregular
heartbeat, leg swelling, numbness and tingling, headaches, coordination loss, weakness, heartburn,
constipation, depression, sleep disturbances, irritability, and mood swings. Id. at 5. Physical
examination revealed that she “has no tenderness to palpation along the spinous processes[;]”
however, she “has an area in the right paraspinal musculature, toward the thoracolumbar junction
where she has focal tenderness. She appears to have acute trigger points in this region.” Id.
Continuing the physical examination, the doctor notes that she “has no tenderness on palpation
toward the lumbosacral junction or the paraspinal musculature….Strength testing is 5/5 in the
EHL, gastrocnemius, tibialis, and quads.” Id. “Her extremities are warm to touch. There is no
edema….no pain with internal rotation of either hip. There is no tenderness over the SI joint.” Id.
There was no allodynia, “at least in her lower extremities.” Id. The doctor’s impression was
“chronic pain syndrome.” Id.

          On May 25, 2016, Petitioner again visited Dr. Aradillas. The physical exam portion of the
visit is identical to the physical exam section detailed in the October 13, 2014 visit (Ex. 23 at 6-8).
Dr. Aradillas assessed Petitioner with CRPS, SFN, and neuropathic spondylopathy of lumbar
spine. Ex. 125 at 39. Dr. Aradillas again confirmed the need for a skin biopsy (presumably to
diagnose SFN). See id.15

        On March 1, 2016, Ms. Dixon-Jones had a follow up visit at National Spine & Pain Centers
(“Spine & Pain”) for her herniated disc. Ex. 120 at 35. She had been receiving epidural steroid
injections and reported “significant improvement in the left side” and complained of “pain
primarily on the right” that “radiate[d] from the lower back into the right lateral foot.” Id. at 36.
MRI revealed disc protrusion on her right side at the L4-5 level. Id.

         On December 7, 2016, Ms. Dixon-Jones had a follow up visit at Spine & Pain for her
herniated disc. Ex. 120 at 4. The record notes that her lower back and right leg pain were
symptoms secondary to a L5-S1 disc herniation. Id. The record also notes her history of CRPS in
her left arm. Id. at 5.

15
     Dr. Aradillas did not perform the skin biopsy. See Tr. at 159.

                                                       17
        Ms. Dixon-Jones had a follow up visit at Spine & Pain on April 27, 2017. Ex. 120 at 48.
The doctor’s impression notes that “[a]t L5-S1 there was mild bilateral foraminal compromise
secondary to disc bulge and facet hypertrophy. This could account for the radicular symptoms in
the leg.” Id. at 49. Regarding her CRPS, the record notes that she was “receiving ketamine
injections to the neck region for the CRPS in the left arm.” Id. at 50.

        On November 15, 2017, Ms. Dixon-Jones had a follow up visit at Spine & Pain for her
spondylosis in her lumbar region. Ex. 120 at 1. At this visit, she reported that her pain was better
with medication and treatment, and she described her pain as intermittent throughout the day. Id.
Her pain was burning, chronic, sharp, and radiating. Id. Associated symptoms were weakness
and stiffness. Id. The medical record discusses her history of lower back and right lower extremity
pain due to her L5-S1 disc herniation, and notes that she “has a history of CRPS in the left arm”
that began after her flu vaccination. Id. at 1-2.

III. Fact Testimony

       Ms. Dixon-Jones testified at hearing. She described her health and medical condition both
before and after her October 6, 2011 flu vaccination. Before the vaccination, Petitioner testified
that she and her husband used to host Thanksgiving dinner and Christmas brunch for
approximately 30 people. Tr. at 14. After the vaccination, they no longer hosted either event. Id.
at 16.

         Ms. Dixon-Jones also discussed various activities that she used to enjoy that she has needed
to modify since her flu vaccination. For example, she and her husband enjoy camping. They still
go camping, but Ms. Dixon-Jones no longer rides her bike as much as she used to during these
trips. Tr. at 21. She also no longer hikes. Id. at 22. In addition to camping, Ms. Dixon-Jones
testified that she used to enjoy cross stitch, shopping, and gardening. Id. at 22-23. After her flu
vaccination, she no longer does cross stitch, and she has limited her shopping and gardening. Id.

        Ms. Dixon-Jones testified that she is not confident in her memory regarding the timing of
her medical symptoms and medical events. Tr. at 23-24. She stated that she did agree with the
timeline of symptoms recorded in her medical records. Id. at 24. Ms. Dixon-Jones testified briefly
about the VAERS report that was filed in this case, and specifically about the fact that “first time
flu shot” was handwritten on that record. Ms. Dixon-Jones testified that she did not fill that form
out and does not recall telling the nurse that it was her first flu vaccination. Id. at 25. She testified
that she has received a total of two flu vaccinations. Id.

        Petitioner discussed the treatment she has been receiving from Dr. Aradillas and testified
that these treatments have helped her, although she is still not back to her state of health from
before the flu vaccination. Tr. at 27-28.




                                                   18
IV. Expert Opinions

     A. Dr. Enrique Aradillas-López

       Petitioner filed one expert report from Dr. Aradillas, and he also testified at the hearing.
See Expert Report, filed as Ex. 37 (ECF No. 26-1), hereinafter “Aradillas Rep.”.

        Dr. Aradillas received his medical degree from La Salle University of Medicine in Mexico
City, Mexico. See Aradillas CV, filed as Ex. 38 (ECF No. 26-2) (“Aradillas CV”). He completed
his internal medicine residency at Interfaith Medical Center in Brooklyn, New York, and a
residency in neurology at the Drexel University College of Medicine in Philadelphia,
Pennsylvania. Id. at 1. Following his residencies, Dr. Aradillas completed an interventional pain
management fellowship at Penn State University in Hershey, Pennsylvania. Id. Dr. Aradillas is
board certified in neurology, and holds a position as an assistant professor, and the Chief of the
Division of Pain in the Department of Neurology at Drexel University. Id.

        Currently, Dr. Aradillas works as the director of the Neuropathic Pain Center at the Vincera
Institute in Philadelphia, Pennsylvania. Aradillas Rep. at 1. For the past six years, Dr. Aradillas
has treated patients with chronic neuropathic pain, particularly CRPS and SFN. Id. In his practice,
Dr. Aradillas has evaluated several thousand patients with CRPS. Id. In collaboration with Drexel
University, Dr. Aradillas has several grants, two with the National Institutes of Health, and one
pharmaceutical grant to study a new therapy for CRPS. He has published several articles in the
areas of pain and CRPS. Aradillas CV at 3-4. I recognized Dr. Aradillas as an expert in neurology
and CRPS.

        In his report and at the hearing, Dr. Aradillas opined that Petitioner developed CRPS as a
result of the flu vaccine she received on October 6, 2011. Aradillas Rep. at 2.

       1. Budapest Criteria

         According to Dr. Aradillas, CRPS is a chronic and incurable condition, which affects the
central nervous system (or the entirety of the spinal cord). Tr. at 51-52. The Budapest Criteria are
well accepted in the medical community as the diagnostic criteria for CRPS. Id. at 45. The
Budapest Criteria were validated by an article written in 2009 entitled, “Validation of proposed
diagnostic criteria (the ‘‘Budapest Criteria”) for Complex Regional Pain Syndrome.”16 The
criteria include:

       1) Continuing pain, which is disproportionate to any inciting event
       2) Must report at least one symptom in three of the four following categories:
          - Sensory: reports of hyperesthesia and/or allodynia
          - Vasomotor: reports of temperature asymmetry and/or skin color changes and/or
             skin color asymmetry


16
  Harden RN, et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex
Regional Pain Syndrome. PAIN 2010; 150: 268-74 (filed as Ex. 39; hereinafter referred to as Ex. 39).


                                                19
           -  Sudomotor/edema: reports of edema and/or sweating changes and/or sweating
              asymmetry
           - Motor/trophic: reports of decreased range of motion and/or motor dysfunction
              (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
       (3) Must display at least one sign at time of evaluation in two or more of the following
       categories:
           - Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch
              and/or deep somatic pressure and/or joint movement)
           - Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or
              asymmetry
           - Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating
              asymmetry
           - Motor/trophic: evidence of decreased range of motion and/or motor dysfunction
              (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
       (4) There is no other diagnosis that better explains the signs and symptoms

        The diagnosis for CRPS is made clinically, meaning that it “is made only based on
symptoms and physical exam findings.” Tr. at 45. Since CRPS is a clinical diagnosis, there is no
test that can be performed to diagnose it. Id.

         In addition to explaining the four categories listed in the Budapest Criteria, Dr. Aradillas
described how he determines whether his patients have signs of the disease. Regarding the sensory
category, Dr. Aradillas testified that he examines his patients by using “a tuning fork to test for
cold allodynia, and the tuning forks are usually cold, so if [the patient] report[s] that it hurts, then
that’s enough…for the physical exam finding, or if the pinprick hurts more than [expected], then
that’s also enough for the physical exam finding part.” Tr. at 48. Regarding the vasomotor
category, he looks for skin color changes or skin color asymmetry. Id. at 48-49. Regarding
temperature asymmetry, Dr. Aradillas “usually send[s] [patients] to get another specialized
test.…[He doesn’t] have a thermometer in the office.” Id. at 49. Regarding the sudomotor and
edema category, he compares the extremities and looks for swelling. Id. Dr. Aradillas performs
“a neurological examination, motor exam, and determine[s] if there’s weakness or not. And then
for the skin and nails and hair changes, [he] just inspect[s] the patient [to] see if [he] find[s] any
of this.” Id. In his practice, Dr. Aradillas states that about 30% of his patients present with obvious
clinical changes while the remainder of his patients have more subtle changes. Id. at 50.

        Citing medical literature, Dr. Aradillas noted that a characteristic of CRPS is pain spread.
Spread of pain occurs in part because “irreversible activation of the postsynaptic nerve happens
not only on the level of injury, but there is a communication within these neurons in the spinal
cord which eventually leads to the activation of the postsynaptic neuron at all levels of the spinal
cord.” Tr. at 73. Describing the pain that CRPS patients experience, Dr. Aradillas testified that
individuals “will develop this natural wear and tear of the body, but because the whole pain system
is now sensitized, this new or this chronic pain -- normal chronic pain condition in a patient with
CRPS will be experienced [as] extra painful.” Id. at 74. Further, “this extra input of pain…because
there’s still a message of pain that is going into the spinal cord, will continue to perpetuate these
changes.” Id.



                                                  20
        2. CRPS Diagnosis

          Dr. Aradillas saw Petitioner for the first time on October 13, 2014. See Ex. 23 at 6-9. He
testified that Petitioner fulfilled the “symptom requirement” of the Budapest criteria during this
initial visit because:

        [s]he complained to me of pain that was continuous, that started after she received
        the flu vaccine on October 6th of 2011. So she had that….She also complained to
        me at that time of pain to touch. She complained to me of hugs, specifically. She
        didn’t like people hugging her, touching her, because that really hurt. She also
        admitted to have noted that her extremities at times were cold or hot. She also said
        to me that she has noticed, during the course of those three years, swelling that
        came and went, and she complained to me of severe upper extremity weakness,
        especially in the hands and some of it in the lower extremities, but most notably in
        the hands….She basically had a complaint on each one of the symptom categories,
        sensory, the vasomotor category, the sudomotor category, and the motor and
        trophic category.

Tr. at 114-15.

        He further testified that Petitioner fulfilled the “signs requirement” of the Budapest criteria
based on his findings during her physical examination. Tr. at 115. Regarding the sensory category,
Dr. Aradillas found that Petitioner had positive Roos and Wright brachial plexus abduction
maneuvers, positive Tinel sign, positive Arcade of Frohse, joint pain, deep sensitization, and
allodynia.17 Id. at 115-16. She also had hyperpathia and hyperalgesia. Id. at 118. Regarding the
vasomotor category18,19, Dr. Aradillas found that Petitioner had glove distribution (loss of
sensation to pain and temperature), loss of sensation to pain in the hand, and temperature on the
right and left sides.20 Id.


17
  Dr. Aradillas describes Roos and Wright as “a maneuver that stretches the brachial plexus. If you have a
brachial plexus injury, then you will have a positive Roos and Wright abduction maneuver.” Tr. at 115-16.
He states that a Tinel sign “refers to a sensitized peripheral nerve that you can press on that is proximal --
in close proximity to the surface, so you can press on it. The most common Tinel sign or the most well
known happens when you develop carpal tunnel.” Id. at 116. He describes Arcade of Frohse as “an
anatomical structure under which the radial nerve passes as it branches into the superficial and the deep,
and it branches, and the median nerve also goes underneath it.” Id.
18
  Goebel A. Complex regional pain syndrome in adults. RHEUMATOLOGY 2011; 50: 1739-50. (filed as Ex.
56; hereinafter referred to as Ex. 56).
19
  The Budapest criteria require that the temperature asymmetry, if noticed by the physician, be greater than
1 degree Celsius. Ex. 56 at 3 (“If you notice temperature asymmetry: must be > 1C”). Dr. Aradillas
testified that his general practice is to refer his patients to another physician for temperature measurement
because he does not have a thermometer in his office. Tr. at 49.
20
  On November 25, 2014, Petitioner underwent QST testing at Drexel University. QST is defined as “the
determination of thresholds or stimulus response curves for sensory processing under normal and

                                                     21
       She also had erythema (redness) of both shoulders in the supraclavicular fossa, purplish
discoloration of both hands. Id. Regarding the sudomotor/edema category, Petitioner had swelling
on the right arm and swelling of both hands (worse on the left hand). Id. Regarding the
motor/trophic category, Dr. Aradillas noticed she had decreased strength on her right upper
extremity in comparison to her left, and she had decreased facilitation of fine motor movements
on both upper extremities. Id. at 119. Dr. Aradillas stated that he “basically found one of each
categories -- or one of -- one sign in each of the categories for -- to fulfill the criteria for CRPS.”
Id.

        3. Dr. Aradillas’ Presentation of Petitioner’s Pre-Vaccination Medical History

        Dr. Aradillas highlighted the importance of Petitioner’s pre-vaccination medical history in
order to support Petitioner’s diagnosis of CRPS. He appeared to do this for two reasons: (1) the
Budapest criteria requirement that “[n]o other diagnosis can better explain the signs and
symptoms” (see Ex. 56 at 3) is satisfied, in Dr. Aradillas’ opinion, because he believes that
Petitioner does not have fibromyalgia; and (2) her medical history shows that her prior pain
amplified post-vaccination, which according to him, is a characteristic of CRPS pain.

        On January 4, 2000, Petitioner was seen in the ER due to her motor vehicle accident (Ex.
10 at 81), and Dr. Aradillas explained that her accident caused her to suffer a whiplash injury,
which usually injures the brachial plexus. Tr. at 98. Dr. Aradillas described the brachial plexus as
branches of a tree, stating, “nerves are like trees in the literal sense, because when they come out
of the spine, we call them nerve roots, and then these roots, they come together and form a trunk”
and “whenever this tree is supposed to go, it branchs [sic]. We don’t call them trees, we call them
plexus.” Id. Dr. Aradillas opined that, based on Petitioner’s whiplash injury, she injured her left
and right brachial plexus. Id. at 99-100. He further opined that her neck spasms that radiated to
both of her hands suggest a brachial plexus injury. Id. at 100. He also noted that her pain was
intermittent, which is not characteristic of CRPS. Petitioner’s records from January 4, 2000 also
note her neck pain radiating to her arm and her having radiculopathy. See Ex. 10 at 73. Dr.
Aradillas posits that she did not have CRPS at this time because her pain was simply radiating
down her arm; there was no central sensitization at this time because she did not have amplified
pain. Id. at 101. Petitioner reported that her pain was relieved by nothing, which suggests to Dr.
Aradillas that her pain was orthopedic in nature. Id.

       On July 14, 2000, Petitioner had a right radial sensory nerve compression of the forearm
Ex. 15 at 16. Dr. Aradillas testified that she developed pain in the distribution of the radial nerve

pathological conditions.” Uddin Z, MacDermid JC. Quantitative Sensory Testing in Chronic
Musculoskeletal Pain. PAIN MED 2016; 17: 1694-703 (filed as Ex. 111; hereinafter referred to as Ex. 111).
QST is considered semi-subjective. Id. at 1. It assesses subjective responses to a controlled stimulus. Id.
The results for the hands and forearms indicated “evidence of mild cold thermal (Aᵟ fiber mediated) sensory
deficit in the right hypothenar, and mild warm thermal (C fiber mediated) sensory deficits in the hypothenar
bilaterally. Evidence of cold allodynia bilaterally.” Ex. 36 at 47. The results for the feet indicated normal
sensory detection thresholds. Further, that “[c]utaneous temperatures were warm with asymmetries in toes
II-IV, right warmer than left.” Id. This finding of temperature asymmetry and loss of sensation to cold is
consistent with Dr. Aradillas’ physical exam that he performed on October 13, 2014.

                                                     22
from her brachial plexus injury that was caused by her motor vehicle accident. Tr. at 102. He
stated that her doctors found compression between the brachial radialis and extensor carpi radialis
tendons (in the forearm – elbow downward). Id.

        Dr. Aradillas attributed Petitioner’s left and right carpal tunnel syndrome in 2001 to her
motor vehicle accident because brachial plexus injuries can put one at risk to develop carpal tunnel.
See Ex. 15 at 70 (Petitioner’s right carpal tunnel release procedure); Ex. 15 at 46 (Petitioner’s left
carpal tunnel release procedure). Dr. Aradillas testified that there is no indication Petitioner had
CRPS at this point in time. Tr. at 103-05.

        According to Dr. Aradillas, Petitioner’s mid and lower back pain in 2005 can be attributed
to the abnormalities found in her spine; in other words, her MRI findings clinically correlated with
the pain she was experiencing. See Ex. 123 at 49, 50 (MRI findings of thoracic spine and
lumbosacral spine). See also Tr. at 109-10.

        Dr. Aradillas discussed Petitioner’s June 15, 2006 visit, when she had a nerve conduction
study that resulted in a diagnosis of pancreatitis (Ex. 18 at 29); he testified that pancreatitis is an
inflammation process that can trigger the exacerbation of chronic pain. Tr. at 106.

         Petitioner had abdominal pain in 2008, which Dr. Aradillas attributed to her increased
intake of Advil. Tr. at 111. She was taking more Advil due to her backaches, and Dr. Aradillas
testified that Advil is known to cause gastritis and the exacerbation thereof. Id. See also Ex. 19
at 7 (Petitioner had a gastroenterology consultation for abdominal pain and notes she was taking
more Advil); Ex. 19 at 5 (Petitioner had a follow up appointment for her abdominal pain for her
chronic gastritis).

        According to Dr. Aradillas, Petitioner’s MRI of the thoracic spine on October 4, 2009 also
clinically correlated with the intermittent pain she was experiencing. See Ex. 125 at 209. Dr.
Aradillas believes that these MRI findings explain Petitioner’s chronic back pain and that there
was no indication of the central sensitization process. Tr. at 95.

       Petitioner was admitted to Northwest Hospital Center for abdominal pain in March 2010
(Ex. 11 at 214-15), and Dr. Aradillas stated that her abdominal pain had the same characteristics
as her prior abdominal pain in 2008. Tr. at 112-13. Her discharge summary, dated March 31,
2010, noted that she had gallstones. Ex. 11 at 204. Dr. Aradillas testified that Petitioner’s
abdominal pain resolved once treaters removed her gallbladder. Tr. at 113.

       4. Fibromyalgia

       Dr. Aradillas testified that Petitioner was incorrectly diagnosed with fibromyalgia in 2006.
He is uncertain who diagnosed her and what criteria were used in order to make such a diagnosis.
He stated that the diagnostic criteria for fibromyalgia were developed in 201021 (see Ex. 71 at 8

21
  Wolfe F, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia
and Measurement of Symptom Severity. ARTHRITIS CARE RES 2010; 62(5): 600-10 (filed as Ex. 71;
hereinafter referred to as Ex. 71).


                                                  23
(the diagnostic criteria for fibromyalgia are satisfied when the following three conditions are met:
(1) widespread pain index of greater than or equal to 7 and symptom severity scale score of greater
than or equal to 5, or widespread pain index of 3 to 6 and symptom severity scale score of greater
than or equal to 9; (2) symptoms were present at a similar level for at least three months; and (3)
the “patient does not have a disorder that would otherwise explain the pain.”)). Dr. Aradillas points
out that Petitioner had no indication of any other symptomatology than in her arms. Tr. at 107.
Furthermore, Dr. Aradillas opined that Petitioner could not have fibromyalgia because in his view,
Petitioner’s medical history provides an explanation for her pain.

          5. Dr. Aradillas’ Causation Theory

        Prior to explaining Petitioner’s medical theory in this case, Dr. Aradillas provided detailed
information regarding pain and the communication of pain. Pain can be either neuropathic (injury
to the nervous system), somatic (non-injury to the nervous system), or nociceptive22 (A delta fiber
or C fiber). Tr. at 63-65. Pain is communicated by way of the presynaptic neuron to the
postsynaptic neuron, and there are also immune cells living in the central nervous system (“CNS”),
which are known as astrocytes and microglia. Id. at 67. Astrocytes regulate the amount of
neurotransmitters, specifically glutamate. Id. at 68. The effect on postsynaptic neurons will
depend on the activation of these immune cells. Id. Once pain is communicated up the spinal cord
to the brain, the process of stopping the communication of pain involves transmitting the release
of inhibitory neurotransmitters in the synapse from the brain down to the spinal cord (descending
nociceptive inhibitory control system). Id. at 70-71.

        A process known as “central sensitization” occurs when the inhibitory neurotransmitters
malfunction, thus resulting in an inability to turn off pain signals. Tr. at 71. Central sensitization23
is a process that leads to the development of CRPS.24 The main mechanisms involved in central
sensitization, which must occur together, are the neuronal mechanism and the immune cell
mechanism (regarding the immune cells that surround neurons). Id. at 60, 76.

                  a. Prong 1

          Dr. Aradillas’ medical theory in this case was stated as follows:

          the [flu] vaccine caused the normal activation of the innate system, causing
          increasing inflammatory cytokines to circulate, plus the vaccine also caused an

22
     Nociceptors can be activated by mechanical stimulus (noxious stimulus) or by the immune system.
23
   According to Dr. Low, central sensitization is a process that creates many chronic pain syndromes,
including the development of CRPS. Dr. Low states, “…all we heard about is maybe the previous pain that
she had took on different characteristics….You were shown…slides about pathways, amplification, and
central sensitization. First of all, that’s not specific to CRPS. That occurs in neuropathies, it occurs in other
conditions, so it really does not mean much.” Tr. at 191-92.
24
   CRPS divides into two subtypes, Type I and Type II. If an individual has a nerve injury, his or her CRPS
is classified as Type II. Tr. at 43-44.


                                                       24
        allergic reaction, causing the degranulation of mast cells, which both together
        caused the permanent activation of microglia and astrocytes, glial cells surrounding
        the synapse of the pain transmission neurons, which led to this permanent
        glutamate-dependent neuroplasticity or central sensitization syndrome and
        manifested clinically as a worsening of her or amplified her old pains and the
        development of complex regional pain syndrome.

Tr. at 131.

        Dr. Aradillas testified that a noxious event, traumatic or non-traumatic, can cause CRPS.
Tr. at 152. In his experience, 60% of his patients experienced a traumatic event (i.e., fracture, torn
limb, and amputation) and 40% of his patients experienced a non-traumatic event (i.e., needle
stick, blood work, IV placement, and walking on an extremely cold surface). Tr. at 152-53.
Despite such causes, Dr. Aradillas is of the opinion that “the vaccine triggered the central
sensitization syndrome…which amplified her old pains. Rather than the needle stick itself.” Tr.
at 154-55. Dr. Aradillas does not “believe that the vaccine caused a local injury[;]” he believes
“that the vaccine triggered her immune system to react in an allergic way, which triggered the
central sensitization, [which] triggered her [] amplified pain on the region where she [] had chronic
pain.” Tr. at 155. Dr. Aradillas explained that her region of pain was the exacerbation of her old
pain rather than from pain at the initial site because, in his opinion, there was no noxious event
that caused her to have CRPS. Rather, an autoimmune response amplified and created a spread of
her old pain. Tr. at 142 (explaining that Petitioner’s region of pain was in “her left buttock, right
buttock, all the way down to the knees…bilaterally” and that “pain doesn’t need to start where the
injury starts”).

                b. Prong 2

       Dr. Aradillas concludes that the flu vaccination stimulated Petitioner’s immune system,
which triggered her CRPS. Tr. at 86. Such activation occurred by her allergic reaction to the flu
vaccine and the vaccine itself–both resulted in the activation of her immune system. Id.

        Using the Budapest Criteria as a framework, Dr. Aradillas opined that Petitioner met each
of the four criteria. Dr. Aradillas referenced Petitioner’s medical records to support the fact that
Ms. Dixon-Jones had been experiencing continuing pain during the 2012 timeframe. Aradillas
Rep. at 6. In support of the second criterion, Dr. Aradillas stated that Petitioner has reported both
hyperesthesia and allodynia to her doctors. Further, his exam of Petitioner revealed that she had
swelling of the left supraclavicular fossa, erythema, and obvious livedo reticularis all throughout
the upper extremities. She also had erythema and diaphoresis, especially at the hands. Finally,
Dr. Aradillas observed some dystrophic changes on the fingernails. Id. at 13-14.

        Dr. Aradillas highlighted medical events subsequent to Petitioner’s October 6, 2011
vaccination that reflect the initiation of the central sensitization process that developed into CRPS.
Petitioner had an allergic reaction to the flu vaccine, which is noted on October 12, 2011. Ex. 26
at 27. Dr. Aradillas notes that her allergic reaction was her first initial pain as well as the activation
of her immune system. In support of his assertion, Dr. Aradillas references a study that measured



                                                   25
the production of inflammatory cytokines in participants who received flu vaccine.25 The study
explained how flu vaccine can stimulate the innate immune system, and Dr. Aradillas noted that
the results from the study revealed “that the production of tumor necrosis factor alpha and
interleukin 6 after a vaccination is associated with antibody response to the influenza vaccine[.]”
Tr. at 88.

        He opines that her abdominal pain on October 23, 2011 (Ex. 11 at 8) was indicative of the
central sensitization process. Four weeks after her vaccination, on November 4, 2011, Petitioner
reported ear pain that worsened when touched. Ex. 20 at 4. Dr. Aradillas explains her ear pain
was allodynia (an experience of pain from a non-painful stimulus). He opines that the central
sensitization process was beginning to occur.

       Petitioner’s abdominal and back pain, described as a burning and band-like pain, on
November 8, 2011 is, in Dr. Aradillas’ opinion, indicative of the central sensitization process
because her old pains were being amplified. Tr. at 126-29. He explains that her pain had a new
description of being bilateral in her upper abdomen and chest, and that her burning sensation was
a neuropathic feature. Id. at 130.

        Dr. Aradillas points out that her pain on December 9, 2011 (Ex. 16 at 23) was indicative
of the central sensitization process occurring as well as CRPS. He explains that Petitioner’s old
pain was only in her low back as reflected in a diagram (see Ex. 13 at 38), while her new pain is
low back pain that radiates down to her right and left knees, her left and right buttocks.26 She also
had muscle stiffness and described her pain as burning, aching, and constant. In his opinion, her
old pain was amplified, which is characteristic of the central sensitization process and CRPS. He
also noted that she was showing motor symptoms and having constant, not intermittent, pain,
which is indicative of CRPS. Dr. Aradillas explains that Doppler tests are usually conducted for
leg swelling, which Petitioner underwent on February 2, 2012 (Ex. 11 at 48). Tr. at 130.

       Dr. Aradillas is of the opinion that Petitioner met the diagnostic criteria for a CRPS
diagnosis on February 6, 2012.

                   c. Prong 3

        Dr. Aradillas believes that CRPS began at a temporally appropriate time with respect to
Petitioner’s flu vaccination, pointing out that onset of her symptoms was on November 4, 2011,
four weeks after vaccination. Tr. at 137 (stating that “pain in her face” was the first symptom of
CRPS). On such date, she reported ear pain that worsened when touched, which, according to Dr.
Aradillas was allodynia and an indication that her central sensitization process began.

        B. Dr. Phillip Low

25
   Mohanty S, et al. Prolonged Proinflammatory Cytokine Production in Monocytes Modulated by
Interleukin 10 After Influenza Vaccination in Older Adults. J INFECT DIS 2015; 211: 1174-84 (filed as Ex.
105; hereinafter referred to as Ex. 105).
26
     As discussed infra, this is not an accurate summary of the medical records.

                                                      26
       Dr. Low offered a single expert report in this case and testified at the hearing. See Expert
Report, dated March 21, 2016, filed as Ex. A (ECF No. 33-1); Tr. at 162-221.

       Dr. Low received his medical and research doctorate degrees from the University of
Sydney in Sydney, Australia. See Low CV, filed as Ex. B (ECF No. 33-2) (“Low CV”). Following
graduation, Dr. Low completed a fellowship in internal medicine with the Royal Australian
College of Physicians. Low CV at 2. Currently, Dr. Low serves as Professor of Neurology at the
Mayo Clinic Medical School. Low CV at 4.

       During his time with the Mayo Clinic, Dr. Low served in various departmental and
academic capacities, including Director of the Neuroscience Laboratory, Director of the
Autonomic Reflex Laboratory, and Chairman of the Division of Clinical Neurophysiology. Low
CV at 3-4. At Mayo, he founded the autonomic reflex lab. Tr. at 164. Dr. Low has co-authored
over 400 items of literature in the field of autoimmunity, including the largest series of publications
centered on antibody-mediated autoimmune neuropathies. Id. at 167; see also Ex. B at 9-50. Dr.
Low has also served on the editorial boards of multiple journals centered on autonomic and
nervous system research, including the Journal of Clinical Neurophysiology. Low CV at 5. He
also consistently serves as a research advisor to postdoctoral fellows at the Mayo Clinic Medical
School. Id. at 7-9.

        Over the course of his career, Dr. Low’s time has been divided between patient practice
and research. Tr. at 165. Dr. Low’s clinical practice is focused on autonomic disorders, including
work heading clinical trials on autonomic disorders and drug trials. Id. Dr. Low sees about 10
patients per week for CRPS; however, “the numbers that have turned out to be positive are far
less.”27 Id. Dr. Low has served as a reviewer in peer-reviewed medical journals, such as New
England Journal of Medicine, Lancet, Neurology, and the British Medical Journal. Id. at 168. I
recognized Dr. Low as an expert in neurology. Dr. Low was highly qualified to provide expert
testimony in this case.

        Dr. Low does not believe that Petitioner has CRPS and disagrees that Dr. Aradillas
correctly diagnosed her with CRPS. Dr. Low bases his conclusion on the medical records, which
he states do not support this diagnosis. See generally Tr. at 162-221.

        1. Budapest Criteria: Weaknesses and Objective Measurements




27
  Dr. Low testified that he treats patients with CRPS; however, he declined to provide exact details on how
he treats his patients. Dr. Low expressed that he does not conduct IVIG treatments for his patients with
CRPS, describing such treatment as ineffective. Tr. at 198. See also Tr. at 205 (“I don’t use ketamine
infusions, and I don’t use IVIg”); Goebel A, et al. Low-Dose Intravenous Immunoglobulin Treatment for
Long-Standing Complex Regional Pain Syndrome. ANN INTERN MED 2017; 167(7): 476-83 (filed as Ex.
K; hereinafter referred to as Ex. K) (“Low-dose immunoglobulin treatment for 6 weeks was not effective
in relieving pain in patients with moderate to severe CRPS of 1 to 5 years’ duration”).


                                                    27
         Dr. Low described CRPS as a rare disease, with an incidence of five per 100,000. Tr. at
165, 176. He explained that the Budapest Criteria28 are the diagnostic standard; however, these
criteria have limitations in that they very much depend on the clinician who makes the diagnosis.
Id. at 217. Dr. Low explained that the weakness of the Budapest Criteria is that the “interpretation
of the signs doesn’t specify a quantitative aspect…but a quantitative aspect is understood, so that
it’s understood that the clinician…should not say that this arm is warmer or colder unless…it really
is at least a degree, and in terms of sweatiness, unless it’s obvious.” Id. While the Budapest
Criteria do not detail how signs should be measured, Dr. Low has a “significant” measurement
approach. Id. at 215. For example, regarding color and sweat changes, Dr. Low noted that such
changes do not “need to be extreme, but it has to be significant, and by ‘significant’ we require a
50 percent difference between sides.” Id. Further detailing his approach in regard to the
symptomalogical asymmetry requirement for the Budapest Criteria, Dr. Low stated that it could
be in the upper or lower extremity, and he looks at three things. Id. at 212-13. Regarding
temperature distribution, “[y]ou might take a thermogram of the upper extremity, and you look at
the distribution of temperatures.” Id. at 213. Regarding sweating, “we would use a larger capsule
that would measure resting sweat activity over the two extremities simultaneously over a defined
period of time.” Id. “And then, thirdly, we would do the QSART29 measurement at two different
levels to -- and also do that simultaneously.” Id. The way in which Dr. Low’s laboratory
objectively documents the signs is by comparing two limbs, “the affected and non[-]affected, side
by side to measure how much sweating differential there is, and then you could document
temperature. You could use a thermogram, for instance, and look at the pattern of sweat -- of
temperature difference, and it’s quite characteristic when we do that.” Id. at 174.

        2. Characteristics of CRPS

        Dr. Low, citing medical literature, defined CRPS as “characterized by a continuing
(spontaneous and/or evoked) regional pain” and as “pain [which] is regional…and usually has a
distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic
findings.”30 Tr. at 171. Dr. Low emphasized that although patients with CRPS can have different
levels of pain, the condition is characterized by regional pain, meaning that “it’s outside of the
distribution of one or more peripheral nerves. It’s usually in a region of the body, such as an arm
or a leg, and the appearance is fairly characteristic.” Id. Dr. Low testified that CRPS pain does

28
  The Budapest Criteria evolved as a remedy to the International Association for the Study of Pain (IASP)
criteria’s limitations, which were dependent solely on what the patient reported to the physician. Tr. at 172.
Due to the need to have both symptoms and signs, the Budapest Criteria were developed; Dr. Low points
out “they recognized that the Budapest criteria had one weakness, and that is it depended solely on what
the physician found. They recognized that -- and actually, it does specify [ ] that you needed at least one
degree Celsius in temperature difference.” Id. at 173. Dr. Low “emphasized it was really necessary to
document how much sweat difference between the two limbs and how much temperature difference there
was.” Id.
29
  Dr. Low notes that QSART is not a part of the Budapest Criteria, as it was made “very clear that it had
to be what’s available to the clinicians who practiced at different levels, at different places.” Tr. at 212.
30
 Harden RN, Bruehl S. Proposed New Diagnostic Criteria for Complex Regional Pain Syndrome. PAIN
MED 2007; 8(4): 326-31 (filed as Ex. C; hereinafter referred to as Ex. C).


                                                     28
spread over time, but when that happens, the patient retains an asymmetry; in other words, if a
CRPS patient has one affected limb, that limb will still be impacted after spread. Id. at 175. The
pain in the initial region does not change much and will not subside unless the condition is
improved. Id. Further, Dr. Low agrees that medical literature supports that one can experience
initial pain in a region that is different from where the patient received his or her needle stick. Id.
at 219.

        Dr. Low further testified that CRPS results in unrelenting pain that is without remission.
The pain “simply doesn’t change.”31 Tr. at 171. For example, a “patient isn’t going to come in
and see one physician and have a normal exam and the next day have severe abnormalities as noted
by someone else.” Id. at 172. Dr. Low expressed that allodynia and hyperalgesia (increased
sensitivity to pain) were “well described” by Dr. Aradillas, “but there also [are] prominent
autonomic manifestations, manifest[ed] as color changes, as swelling, and as sweating, and also
by trophic changes that affect bone, nail, soft tissue, et cetera. It almost invariable -- some say
invariably begins with a lim[b].” Id. at 171. Dr. Low testified that a typical presentation of CRPS
is allodynia, hyperalgesia, and prominent trophic changes.32 Id. at 173. Further, “[i]t will usually
be a limb….You just cannot put the capsule on their skin. They don’t want you to touch them
because of the allodynia and hyperalgesia, and they also have trophic changes that could be quite
problematic.” Id. CRPS does not wax and wane, and diffuse body pain is not a characteristic of
CRPS.33 Fibromyalgia, however, does wax and wane and patients “get periods of improvement
and periods of worsening.” Id. at 175. Petitioner’s remission of pain suggests that she has
fibromyalgia or chronic pain.

        3. Petitioner’s Medical Records

       As noted, the Budapest Criteria require signs and symptoms. In order to make a CRPS
diagnosis in his patients, Dr. Low looks for signs such as changes affecting a region, not one site,
“where there would be a temperature change and a significant temperature change, a color
change….swelling, and…trophic changes.” Tr. at 190-91. Dr. Low emphasized the importance
of quantifiable signs. Regarding symptoms, Dr. Low looks for unrelenting pain with allodynia

31
   During cross-examination, Dr. Low, was provided with the following quote: “CRPS symptoms vary in
severity and duration, although some cases are mild and eventually go away. In more severe cases,
individuals may not recover and may have long-term disability.” Tr. at 220 (citing National Institutes of
Health, Complex Regional Pain Syndrome Fact Sheet (2019), https://www.ninds.nih.gov/disorders/patient-
caregiver-education/fact-sheets/complex-regional-pain-syndrome-fact-sheet (filed as Ex. 94; hereinafter
referred to as Ex. 94)). Dr. Low clarified that such a quote “refers to patients who recover….[Y]ou could
have terrible disease, stay steady, what I’m referring to, one two, three, four weeks, and then the patient
gets better. That can occur, but during the time that you have that monophasic illness, your symptoms are
relatively stable.” Tr. at 220-21.
32
   “Trophic changes could be trophic changes to hair. It could fall off or it could be fairly thick; could be
thickening of skin. There’s obviously swelling, and the nails could grow excessively, and the bone changes
are actually very characteristic.” Tr. at 173.
33
  Dr. Low explains that diffuse body pain occurs “in many conditions, many painful conditions. It occurs
in the neuropathies, et cetera, but…it’s not specific to CRPS.” Tr. at 176.


                                                     29
and hyperalgesia. Id. at 191. Dr. Low often sees such symptoms in a patient who is requesting
not to be touched due to pain. Id. Dr. Low states that he does not believe that Petitioner’s clinical
course is CRPS that has spread as he does not “get a picture of when it began” and he does not
“have a picture of…sufficient severity, the combination of pain and autonomic findings[,]” which
Dr. Low likes to see before looking at spread. Id.

        During his testimony, Dr. Low highlighted Petitioner’s medical records shortly after her
receipt of flu vaccine. He acknowledged that Petitioner had a brief reaction to flu vaccine that
resolved. See Ex. 132 at 1 (On October 10, 2011 “patient states that she had a flu shot about a
week or two ago and had a reaction to the flu shot; however, that has resolved”); Ex. 26 at 27 (On
October 12, 2011 “skin is clear….no hives….area of the injection on the right arm is not visible”).

        Dr. Low noted that on January 9, 2012, Petitioner’s lower back pain remained unchanged
and that her LESI helped with her low blood pressure. See Ex. 29-33. He explained that her
continued generalized muscle weakness, fatigue, and dizziness that she experienced were not
characteristics of CRPS. Tr. at 182. According to Dr. Low, her diffuse pain noted on February
17, 2012, is from fibromyalgia and not CRPS.34 See Ex. 18 at 7 (Petitioner “complained that she
was having diffuse pain throughout her entire body from her fibromyalgia”). Dr. Low stated that
symptoms of tingling could be neuropathic symptoms, which is a characteristic of CRPS II;
however, this was not the case with Petitioner on her May 7, 2012 visit. 35 See Ex. 16 at 49. Dr.
Low believes that occasional tingling and piercing sensations in random areas are not
characteristics of CRPS; rather, he thinks “those are common symptoms seen in fibromyalgia.”
Tr. at 183.

        Dr. Low saw no signs of CRPS documented by Dr. Kozachuk on June 14, 2012. Tr. at
184. Petitioner had sensory examination of the hands, which were normal to touch; she had no
pain to palpation, and motor exam of the arms was normal. See Ex. 24 at 3. Dr. Low reviewed
Dr. Kozachuk’s neurologic examination of Petitioner on July 25, 2012 where Dr. Kozachuck
conducted a motor, sensory, reflex, and gait examination. Tr. at 184-85; see also Ex. 24 at 5-8.
The exam indicated no pain palpations and normal motor exam of the arms, but abnormal
neurologic exam with increased reflexes in the legs with spread and body myoclonic jerks. Tr. at
184-85.

        Dr. Low testified that on June 17, 2013, Dr. Williams’ examination of Petitioner revealed
normal color and temperature under the categories “left and right vascular.” Ex. 127 at 33.
“[T]hey’re just looking at the color. Vascular on the right side, normal color and temperature. So
there’s no changes in color or that examination….[I]t certainly shows no signs of CRPS.” Tr. at
188. On August 21, 2014, Dr. Williams, according to Dr. Low, “looked carefully on the thorax,
and certainly no erythema, no swelling, normal temperature. Yeah, normal examination, apart from

 Dr. Low thinks “that diffuse pain with trigger points is much more consistent with fibromyalgia than
34

CRPS.” Tr. at 183.
35
   “…the fact that someone has tingling, paresthesias, doesn’t necessarily mean they actually have
neuropathy. There are symptoms obviously coming from nerves, but patients have nerve-type symptoms
for lots of reasons.” Tr. at 184.


                                                 30
his interest in radial neuropathy, as he calls it.” Id. at 189; see also Ex. 127 at 15-19. Dr. Low
was asked whether Dr. Williams’ examination was one that would reveal signs of CRPS to a doctor
like Dr. Williams if such signs were present, and Dr. Low responded, “In fact, this is a very good
-- unusually good examination because of the great interest in minor findings, so that they do a
very careful examination for color, for swelling, et cetera, and there was no evidence of anything
for CRPS.” Tr. at 189.

        4. Dr. Aradillas’ Examination and Diagnosis

       Dr. Low discussed Dr. Aradillas’ examination of Petitioner on October 13, 2014. Tr. at
189; see also Ex. 23 at 6. Dr. Low testified that he would not have diagnosed Petitioner with
CRPS based on the clinical findings because,

        …quantitatively, the changes are very modest. In terms of the color
        changes, I would look for more -- I would like to quantitate the severity; I
        would like to quantity the difference. As far as the hands are concerned, if
        you shook hands with a bunch of people, in normal people, you often find
        a little bit of moisture. I don’t think it means any – you cannot make a
        diagnosis of CRPS based on that.

Tr. at 190. Dr. Low also would not have diagnosed Petitioner with CRPS based on Dr. Aradillas’
findings of CRPS signs on May 29, 2015. Id.; see also Ex. 125 at 36-39. Dr. Low testified that
he looks for “changes not at one site, but affecting a region, where there would be a temperature
change and a significant temperature change, a color change…swelling, and…for trophic
changes.” Tr. at 190-91.

        5. Petitioner’s Bone Scan Results

        On March 28, 2013, Dr. Nasseri conducted a bone scan of Petitioner to rule out CRPS. Ex.
11 at 41. The exam was normal. Id. Dr. Low testified that this normal result further supports his
opinion that Petitioner does not have CRPS. Dr. Low testified that while normal bone scans do
not exclude CRPS, normal results reveal that CRPS is significantly less likely to be present.36 Tr.
at 194. To further support his position, Dr. Low referenced an article based on an epidemiologic
study that was conducted under his guidance.37 “We found that the bone scan sensitivity was

36
   Dr. Low testified that “the reason why it hasn’t been adopted as a gold standard is because different
laboratories do it -- they have some difficulty agreeing, what exactly is normal, where is the cutoff, normal
and abnormal.” Tr. at 193; see also Wertli MM, et al. Usefulness of bone scintigraphy for the diagnosis of
Complex Regional Pain Syndrome 1: A systemic review and Bayesian meta-analysis. PLOS ONE 2017;
12(3): e0173688 (filed as Ex. 102; hereinafter referred to as Ex. 102)(meta-analysis of bone scans).
37
  The article states that “[t]hree-phase bone scan was done in 34/74 (46%) cases. In 29/34 (85%), the scan
showed a pattern consistent with the diagnosis of CRPS. Autonomic testing was done in 40/70 (54%) and
detected asymmetry in sympathetic function in 32/40 (80%).” Sandroni P, et al. Complex regional pain
syndrome type I: incidence and prevalence in Olmsted county, a population-based study. PAIN 2003; 103:
199-207 (filed as Ex. F; hereinafter referred to as Ex. F).


                                                     31
actually quite good, with about 85 percent of patients ha[ving] an abnormal bone scan, and about
the same percent of patients ha[ving] abnormal autonomic function tests.” Id. at 192. Dr. Low
made the point that the data revealed “a sensitivity and specificity of over 80 percent.” Id. at 193.
In Dr. Low’s opinion, the fact that Petitioner’s bone scan results were normal is supportive of his
opinion that she did not suffer from CRPS.

        6. Fibromyalgia

        Dr. Low also highlighted medical records in support of his opinion that Petitioner’s correct
diagnosis was fibromyalgia and not CRPS. He pointed out that there is no evidence of CRPS
found on December 19, 2011, when Petitioner saw her neurologist, Dr. Sellman. See Ex. 18 at 15.
Dr. Sellman noted that Petitioner had completely normal motor function. See id. The only
abnormality found during that visit included her difficulties with tandem walking; however, Dr.
Low does not place a lot of significance on this; he pointed out that often times people who are not
ill have difficulty performing a heel-to-toe walk. Tr. at 181. Dr. Low also testified that Petitioner’s
neurologist noted she had baseline fibromyalgia pain in her arms.38 See Ex. 18 at 16.

        Dr. Low, referencing Petitioner’s medical record dated February 14, 2013, pointed out that
Petitioner “was diagnosed with fibromyalgia syndrome in 2006.” See Ex. 3 at 6. Regarding Dr.
Nasseri’s examination, Dr. Low “thought his examination of the extremities was very careful,
because he talks about looking at the skin, looking at the nail, and looking at muscle strength...”
Tr. at 185. The doctor “also points out numerous tender points39 to examination, but he was a
rheumatologist, so he would specifically seek out tender points, because that is a characteristic of
fibromyalgia.” Id. Dr. Nasseri examined Petitioner’s skin and nails, which revealed “no rash, no
nail bed changes, no varicose veins.” Ex. 3 at 6-7. The examination further revealed that Petitioner
had “numberous [sic] tender points on trunk, and upper and lower extremities” and no other tender
points found. Id. at 7. Dr. Low points out that examination of Petitioner’s skin and nails were
normal, and she did not have swelling. Dr. Low also emphasizes that on March 20, 2013, when
Petitioner was again examined by Dr. Nasseri, the doctor “noted numerous tender points on trunk
and upper and lower extremities; also noted, again, skin was fine, no nailbed changes, and normal
strength. Then he makes his conclusion that she’s got fibromyalgia that’s quite troublesome.” Tr.
at 187; see also Ex. 125 at 137 (doctor noted, “I believe that the symptoms that she is describing
are an exacerbation of her previously diagnosed fibromyalgia. I believe that her fibromyalgia is
very severe.”).

        7. Causation


38
  According to Dr. Low, the medical record references a prior diagnosis of fibromyalgia. Tr. at 181. Dr.
Sellman “mentions that her baseline -- that she has fibromyalgia and that she has some baseline and
continuing fibromyalgia pain.” Tr. at 181.
39
   Explaining the purpose of examining tender points, Dr. Low stated that a doctor asks the patient whether
he or she has soreness in certain areas and the doctor will “press down on it to see whether it hurts or not.
If someone did that to you, you might feel pressure but not pain, whereas with tender points, they feel it as
pain, and the value is if they find that tender point, they could go and inject it.” Tr. at 185-86.


                                                     32
         Dr. Low opined that the cause of CRPS is unknown. Tr. at 218. In regard to the flu vaccine
causing CRPS, Dr. Low testified that he “looked at all the literature that [he] could get his hands
on in terms of flu shot and CRPS, and…most of the literature was on GBS, but in terms of CRPS,
there was virtually nothing.” Tr. at 194. Regarding Dr. Aradillas’ theory, Dr. Low stated that Dr.
Aradillas described “changes that you see at the local area, changes that you see at the brain. In
fact, the changes that he described occur in many painful neuropathies….This process of central
augmentation, of central sensitization…applies to many conditions.” Tr. at 218. Dr. Low also
testified that anyone who experiences pain can have “some autonomic fluctuations, because the
autonomic nervous system is invariably affected when [one has] pain, so that there is some change
in control of the blood vessels and some change in control of sweating, but that doesn’t make it
CRPS.” Tr. at 218.

       In regard to a needle prick causing CRPS, Dr. Low testified that “CRPS has been well
described after needle.” Tr. at 195. He explained that a common trigger is a fracture as well as
surgery, but ultimately CRPS “has been described after needle as well.” Id. Dr. Low, however,
does not see evidence of Petitioner’s flu shot needle stick triggering CRPS. Id.

        Dr. Low testified that “if a vaccine did cause CRPS” then the condition is expected “to
develop rapidly, certainly within two months, probably within a month, that it would reach a peak
fairly quickly, and so linkage by time is critically important.”40 Tr. at 194.

        In summary, Dr. Low believes that Petitioner does not have CRPS; rather, she has a chronic
pain disorder with fibromyalgia and chronic fatigue. Tr. at 220. Dr. Low, applying the Budapest
Criteria along with his objective diagnostic approach, made this conclusion after reviewing
Petitioner’s medical records, with close attention to the signs observed by Petitioner’s treating
physicians. Dr. Low also found it noteworthy that Petitioner had a prior history of chronic pain
and fibromyalgia and points out that none of Petitioner’s treating physicians post-vaccination
diagnosed her with CRPS until her diagnosis made by Dr. Aradillas, which occurred three years
after her vaccination.41

V. Applicable Law

      A. Petitioner’s Overall Burden in Vaccine Program Cases


40
  During cross examination, Dr. Low was asked whether CRPS would manifest itself to satisfy the
Budapest Criteria within a week or so after a noxious event (vaccine administration), to which Dr. Low
answered it is “[h]ard to say” which is why he provided manifestation occurs “within two months, because
sometimes it does take a while to evolve. In fact, following a noxious event, everything in the literature
says that it should occur within two months, usually within a month.” Tr. at 214.
41
   “Between [Dr. Aradillas’] examination and the vaccination, [Petitioner] had been seen by numerous
physicians….who should be expert[s] at either the neurological exam or with pain, and these are people
who have examined her a number of times and who state in their notes that her arms had normal
temperature, normal appearance, no pain, and motor function.” Tr. at 117. Dr. Low highlights “superb”
examinations of Petitioner conducted by Dr. Nasseri, “who not only looked at her limbs carefully,” but also
defined trigger points, which is characteristic of fibromyalgia, and had been injecting her trigger points. Tr.
at 177.

                                                      33
        Under the Vaccine Act, a petitioner may prevail in one of two ways. First, a petitioner may
demonstrate that she suffered a “Table” injury—i.e., an injury listed on the Vaccine Injury Table
that occurred within the time period provided in the Table. § 11(c)(1)(C)(i). “In such a case,
causation is presumed.” Capizzano v. Sec’y of Health & Human Servs., 440 F.3d 1317, 1320 (Fed.
Cir. 2006); see § 13(a)(1)(B). Second, where the alleged injury is not listed in the Vaccine Injury
Table, a petitioner may demonstrate that he suffered an “off-Table” injury. § 11(c)(1)(C)(ii).

         For both Table and non-Table claims, Vaccine Program petitioners bear a “preponderance
of the evidence” burden of proof. § 13(1)(a). That is, a petitioner must offer evidence that leads
the “trier of fact to believe that the existence of a fact is more probable than its nonexistence before
[she] may find in favor of the party who has the burden to persuade the judge of the fact’s
existence.” Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315, 1324 (Fed. Cir. 2010);
see also Snowbank Enter. v. United States, 6 Cl. Ct. 476, 486 (1984) (mere conjecture or
speculation is insufficient under a preponderance standard). Proof of medical certainty is not
required. Bunting v. Sec’y of Health & Human Servs., 931 F.2d 867, 873 (Fed. Cir. 1991). In
particular, a petitioner must demonstrate that the vaccine was “not only [the] but-for cause of the
injury but also a substantial factor in bringing about the injury.” Moberly, 592 F.3d at 1321
(quoting Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344, 1352 (Fed. Cir. 1999));
Pafford v. Sec’y of Health & Human Servs., 451 F.3d 1352, 1355 (Fed. Cir. 2006). A petitioner
may not receive a Vaccine Program award based solely on her assertions; rather, the petition must
be supported by either medical records or by the opinion of a competent physician. Section
13(a)(1).

        In attempting to establish entitlement to a Vaccine Program award of compensation for a
non-Table claim, a petitioner must satisfy all three of the elements established by the Federal
Circuit in Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274 (Fed. Cir. 2005). Althen
requires that petitioner establish by preponderant evidence that the vaccination he received caused
his injury “by providing: (1) a medical theory causally connecting the vaccination and the injury;
(2) a logical sequence of cause and effect showing that the vaccination was the reason for the
injury; and (3) a showing of a proximate temporal relationship between vaccination and injury.”
Id. at 1278.

        Each of the Althen prongs requires a different showing. Under Althen prong one,
petitioners must provide a “reputable medical theory,” demonstrating that the vaccine received can
cause the type of injury alleged. Pafford, 451 F.3d at 1355-56 (citations omitted). To satisfy this
prong, a petitioner’s theory must be based on a “sound and reliable medical or scientific
explanation.” Knudsen v. Sec’y of Health & Human Servs., 35 F.3d 543, 548 (Fed. Cir. 1994).
Such a theory must be only “legally probable, not medically or scientifically certain.” Id. at 549.

        Petitioners may satisfy the first Althen prong without resort to medical literature,
epidemiological studies, demonstration of a specific mechanism, or a generally accepted medical
theory. Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1378-79 (Fed. Cir. 2009)
(citing Capizzano, 440 F.3d at 1325-26). Special Masters, despite their expertise, are not
empowered by statute to conclusively resolve what are complex scientific and medical questions,
and thus scientific evidence offered to establish Althen prong one is viewed “not through the lens

                                                  34
of the laboratorian, but instead from the vantage point of the Vaccine Act’s preponderant evidence
standard.” Id. at 1380. Accordingly, special masters must take care not to increase the burden
placed on petitioners in offering a scientific theory linking vaccine to injury. Contreras v. Sec’y
of Health & Human Servs., 121 Fed. Cl. 230, 245 (2015) (“[p]lausibility … in many cases may be
enough to satisfy Althen prong one” (emphasis in original)), vacated on other grounds, 844 F.3d
1363 (Fed. Cir. 2017). But this does not negate or reduce a petitioner’s ultimate burden to establish
his overall entitlement to damages by preponderant evidence. W.C. v. Sec’y of Health & Human
Servs., 704 F.3d 1352, 1356 (Fed. Cir. 2013) (citations omitted).

        The second Althen prong requires proof of a logical sequence of cause and effect, usually
supported by facts derived from a petitioner’s medical records. Althen, 418 F.3d at 1278; Andreu,
569 F.3d at 1375-77; Capizzano, 440 F.3d at 1326 (“medical records and medical opinion
testimony are favored in vaccine cases, as treating physicians are likely to be in the best position
to determine whether a ‘logical sequence of cause and effect show[s] that the vaccination was the
reason for the injury’”) (quoting Althen, 418 F.3d at 1280). Medical records are generally viewed
as particularly trustworthy evidence, since they are created contemporaneously with the treatment
of the patient. Cucuras v. Sec’y of Health & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993).

        However, medical records and/or statements of a treating physician’s views do not per se
bind the special master to adopt the conclusions of such an individual, even if they must be
considered and carefully evaluated. Section 13(b)(1) (providing that “[a]ny such diagnosis,
conclusion, judgment, test result, report, or summary shall not be binding on the special master or
court”); Snyder v. Sec’y of Health & Human Servs., 88 Fed. Cl. 706, 746 n.67 (2009) (“there is
nothing … that mandates that the testimony of a treating physician is sacrosanct -- that it must be
accepted in its entirety and cannot be rebutted”). As with expert testimony offered to establish a
theory of causation, the opinions or diagnoses of treating physicians are only as trustworthy as the
reasonableness of their suppositions or bases. The views of treating physicians should also be
weighed against other, contrary evidence also present in the record -- including conflicting
opinions among such individuals. Hibbard v. Sec’y of Health & Human Servs., 100 Fed. Cl. 742,
749 (2011) (not arbitrary or capricious for special master to weigh competing treating physicians’
conclusions against each other), aff’d, 698 F.3d 1355 (Fed. Cir. 2012); Caves v. Sec’y of Health &
Human Servs., No. 06-522V, 2011 WL 1935813, at *17 (Fed. Cl. Spec. Mstr. Apr. 29, 2011), mot.
for review den’d, 100 Fed. Cl. 344, 356 (2011), aff’d without opinion, 475 Fed. App’x 765 (Fed.
Cir. 2012).

       The third Althen prong requires establishing a “proximate temporal relationship” between
the vaccination and the injury alleged. Althen, 418 F.3d at 1281. That term has been equated to
the phrase “medically-acceptable temporal relationship.” Id. A petitioner must offer
“preponderant proof that the onset of symptoms occurred within a timeframe which, given the
medical understanding of the disorder’s etiology, it is medically acceptable to infer causation.” de
Bazan v. Sec’y of Health & Human Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008). The explanation
for what is a medically acceptable timeframe must also coincide with the theory of how the relevant
vaccine can cause an injury (Althen prong one’s requirement). Id. at 1352; Shapiro v. Sec’y of
Health & Human Servs., 101 Fed. Cl. 532, 542 (2011), recons. den’d after remand, 105 Fed. Cl.
353 (2012), aff’d mem., 503 F. App’x 952 (Fed. Cir. 2013); Koehn v. Sec’y of Health & Human



                                                 35
Servs., No. 11-355V, 2013 WL 3214877 (Fed. Cl. Spec. Mstr. May 30, 2013), mot. for review
den’d (Fed. Cl. Dec. 3, 2013), aff’d, 773 F.3d 1239 (Fed. Cir. 2014).

      B. Law Governing Analysis of Fact Evidence

        The process for making factual determinations in Vaccine Program cases begins with
analyzing the medical records, which are required to be filed with the petition. Section 11(c)(2).
The special master is required to consider “all [] relevant medical and scientific evidence contained
in the record,” including “any diagnosis, conclusion, medical judgment, or autopsy or coroner’s
report which is contained in the record regarding the nature, causation, and aggravation of the
petitioner’s illness, disability, injury, condition, or death,” as well as the “results of any diagnostic
or evaluative test which are contained in the record and the summaries and conclusions.” Section
13(b)(1)(A). The special master is then required to weigh the evidence presented, including
contemporaneous medical records and testimony. See Burns v. Sec’y of Health & Human Servs.,
3 F.3d 413, 417 (Fed. Cir. 1993) (it is within the special master’s discretion to determine whether
to afford greater weight to contemporaneous medical records than to other evidence, such as oral
testimony surrounding the events in question that was given at a later date, provided that such
determination is evidenced by a rational determination).

        Medical records created contemporaneously with the events they describe are presumed to
be accurate and “complete” such that they present all relevant information on a patient’s health
problems. Cucuras, 993 F.2d at 1528; Doe/70 v. Sec’y of Health & Human Servs., 95 Fed. Cl.
598, 608 (2010) (“[g]iven the inconsistencies between petitioner’s testimony and his
contemporaneous medical records, the special master’s decision to rely on petitioner’s medical
records was rational and consistent with applicable law”), aff’d, Rickett v. Sec’y of Health &
Human Servs., 468 F. App’x 952 (Fed. Cir. 2011) (non-precedential opinion). This presumption
is based on the linked proposition that (i) sick people visit medical professionals; (ii) sick people
honestly report their health problems to those professionals; and (iii) medical professionals record
what they are told or observe when examining their patients in as accurate a manner as possible,
so that they are aware of enough relevant facts to make appropriate treatment decisions. Sanchez
v. Sec’y of Health & Human Servs., No. 11-685V, 2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr.
Apr. 10, 2013), mot. for review den’d (Fed. Cl. Feb. 11, 2019), appeal docketed, No. 19-1753 (Fed.
Cir. 2019); Cucuras v. Sec’y of Health & Human Servs., 26 Cl. Ct. 537, 543 (1992), aff’d, 993
F.2d at 1525 (Fed. Cir. 1993) (“[i]t strains reason to conclude that petitioners would fail to
accurately report the onset of their daughter’s symptoms.”).

        Accordingly, if the medical records are clear, consistent, and complete, then they should
be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-1585V, 2005
WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). Indeed, contemporaneous medical
records are generally found to be deserving of greater evidentiary weight than oral testimony --
especially where such testimony conflicts with the record evidence. Cucuras, 993 F.2d at 1528;
see also Murphy v. Sec’y of Health & Human Servs., 23 Cl. Ct. 726, 733 (1991), aff’d per curiam,
968 F.2d 1226 (Fed. Cir. 1992), (citing United States v. U.S. Gypsum Co., 333 U.S. 364, 396
(1947) (“[i]t has generally been held that oral testimony which is in conflict with contemporaneous
documents is entitled to little evidentiary weight.”)).



                                                   36
        However, there are situations in which compelling oral testimony may be more persuasive
than written records, such as where records are deemed to be incomplete or inaccurate. Campbell
v. Sec’y of Health & Human Servs., 69 Fed. Cl. 775, 779 (2006) (“like any norm based upon
common sense and experience, this rule should not be treated as an absolute and must yield where
the factual predicates for its application are weak or lacking”); Lowrie, 2005 WL 6117475, at *19
(“[w]ritten records which are, themselves, inconsistent, should be accorded less deference than
those which are internally consistent”) (quoting Murphy, 23 Cl. Ct. at 733)). Ultimately, a
determination regarding a witness’s credibility is needed when determining the weight that such
testimony should be afforded. Andreu, 569 F.3d at 1379; Bradley v. Sec’y of Health & Human
Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).

        When witness testimony is offered to overcome the presumption of accuracy afforded to
contemporaneous medical records, such testimony must be “consistent, clear, cogent and
compelling.” Sanchez, 2013 WL 1880825, at *3 (citing Blutstein v. Sec’y of Health & Human
Servs., No. 90-2808V, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). In
determining the accuracy and completeness of medical records, the Court of Federal Claims has
listed four possible explanations for inconsistencies between contemporaneously created medical
records and later testimony: (1) a person’s failure to recount to the medical professional everything
that happened during the relevant time period; (2) the medical professional’s failure to document
everything reported to her or him; (3) a person’s faulty recollection of the events when presenting
testimony; or (4) a person’s purposeful recounting of symptoms that did not exist. LaLonde v.
Sec’y of Health & Human Servs., 110 Fed. Cl. 184, 203-04 (2013), aff’d, 746 F.3d 1334 (Fed. Cir.
2014). In making a determination regarding whether to afford greater weight to contemporaneous
medical records or other evidence, such as testimony at hearing, there must be evidence that this
decision was the result of a rational determination. Burns, 3 F.3d at 417.

     C. Analysis of Expert Testimony

        Establishing a sound and reliable medical theory connecting the vaccine to the injury often
requires a petitioner to present expert testimony in support of her claim. Lampe v. Sec’y of Health
& Human Servs., 219 F.3d 1357, 1361 (Fed. Cir. 2000). Vaccine Program expert testimony is
usually evaluated according to the factors for analyzing scientific reliability set forth in Daubert
v. Merrell Dow Pharm., Inc., 509 U.S. 579, 594-96 (1993). See Cedillo v. Sec’y of Health &
Human Servs., 617 F.3d 1328, 1339 (Fed. Cir. 2010) (citing Terran v. Sec’y of Health & Human
Servs., 195 F.3d 1302, 1316 (Fed. Cir. 1999). “The Daubert factors for analyzing the reliability
of testimony are: (1) whether a theory or technique can be (and has been) tested; (2) whether the
theory or technique has been subjected to peer review and publication; (3) whether there is a known
or potential rate of error and whether there are standards for controlling the error; and (4) whether
the theory or technique enjoys general acceptance within a relevant scientific community.”
Terran, 195 F.3d at 1316 n.2 (citing Daubert, 509 U.S. at 592-95).

        The Daubert factors play a slightly different role in Vaccine Program cases than they do
when applied in other federal judicial fora. Daubert factors are employed by judges to exclude
evidence that is unreliable and potentially confusing to a jury. In Vaccine Program cases, these
factors are used in the weighing of the reliability of scientific evidence. Davis v. Sec’y of Health
& Human Servs., 94 Fed. Cl. 53, 66-67 (2010) (“uniquely in this Circuit, the Daubert factors have

                                                 37
been employed also as an acceptable evidentiary-gauging tool with respect to persuasiveness of
expert testimony already admitted”). The flexible use of the Daubert factors to evaluate
persuasiveness and reliability of expert testimony has routinely been upheld. See, e.g., Snyder, 88
Fed. Cl. at 743. In this matter, (as in numerous other Vaccine Program cases), Daubert has not
been employed at the threshold to determine what evidence should be admitted, but instead to
determine whether expert testimony offered is reliable and/or persuasive.

         Respondent frequently offers one or more experts of his own in order to rebut a petitioner’s
case. Where both sides offer expert testimony, a special master’s decision may be “based on the
credibility of the experts and the relative persuasiveness of their competing theories.”
Broekelschen v. Sec’y of Health & Human Servs., 618 F.3d 1339, 1347 (Fed. Cir. 2010) (citing
Lampe, 219 F.3d at 1362). However, nothing requires the acceptance of an expert’s conclusion
“connected to existing data only by the ipse dixit of the expert,” especially if “there is simply too
great an analytical gap between the data and the opinion proffered.” Snyder, 88 Fed. Cl. at 743
(quoting Gen. Elec. Co. v. Joiner, 522 U.S. 136, 146 (1997)). A “special master is entitled to
require some indicia of reliability to support the assertion of the expert witness.” Moberly, 592
F.3d at 1324. Weighing the relative persuasiveness of competing expert testimony, based on a
particular expert’s credibility, is part of the overall reliability analysis to which special masters
must subject expert testimony in Vaccine Program cases. Id. at 1325-26 (“[a]ssessments as to the
reliability of expert testimony often turn on credibility determinations”); see also Porter v. Sec’y
of Health & Human Servs., 663 F.3d 1242, 1250 (Fed. Cir. 2011) (“this court has unambiguously
explained that special masters are expected to consider the credibility of expert witnesses in
evaluating petitions for compensation under the Vaccine Act”).

     D. Consideration of Medical Literature

        Although this decision discusses some but not all of the medical literature in detail, I
reviewed and considered all of the medical records and literature submitted in this matter. See
Moriarty v. Sec’y of Health & Human Servs., 844 F.3d 1322, 1328 (Fed. Cir. 2016) (“We generally
presume that a special master considered the relevant record evidence even though [s]he does not
explicitly reference such evidence in h[er] decision.”); Simanski v. Sec’y of Health & Human
Servs., 115 Fed. Cl. 407, 436 (2014) (“[A] Special Master is ‘not required to discuss every piece
of evidence or testimony in her decision.’” (citation omitted)), aff’d, 601 F. App’x 982 (Fed. Cir.
2015).

VI. Analysis

        Because Petitioner does not allege an injury listed on the Vaccine Injury Table, Petitioner’s
claim is classified as “off-Table.” As noted above, to prevail on an “off-Table” claim, Petitioner
must prove by preponderant evidence that she suffered an injury and that this injury was caused
by the vaccination at issue. See Capizzano, 440 F.3d at 1320.

     A. CRPS Generally

     CRPS is “a severe chronic pain condition characterized by sensory, autonomic, motor and



                                                 38
dystrophic signs and symptoms.”42 Specifically, the signs and symptoms of CRPS involve four
main categories: (1) abnormalities in pain processing that can include allodynia, where a non-
painful stimulus is perceived as painful, and hyperalgesia, an enhanced pain response; (2)
vasomotor symptoms which can involve skin color changes or asymmetry and/or temperature
asymmetry between the extremities; (3) swelling, and changes/asymmetry in sweat function; and
(4) motor dysfunction which can include weakness, reduced range of motion, and tremor, and
trophic changes that may affect bone, nail, hair, and skin. Ex. 39 at 7. Although the cause of
CRPS is unknown, it typically develops after some type of trauma to a limb.43 This trauma
typically involves surgeries, fractures, crush injuries, and sprains.44 It can, however, develop after
a minor injury, and has been reported after needle stick.45,46,47,48

      Ninety-two percent of CRPS patients reported that their pain spread to other areas of their
body from where it originally started.49 Contiguous spread was most common early in the course
of the disease (1-2 years) whereas spread to all extremities was most often seen after 15 years. Id.
In terms of the quality of the pain: “The pain in CRPS is continuous, it worsens over time, and is
usually disproportionate to the severity and duration of the inciting event.” Ex. 43 at 1.

      B. The Expert Testimony

       I have evaluated the opinions of both experts in this case and find that Dr. Low’s testimony
was the more persuasive of the two. Both experts were qualified to testify about CRPS, and in
fact, Dr. Aradillas was offered and qualified as an expert specifically in the field of CRPS.

42
  Alexander GM, et al. Changes in immune and glial markers in the CSF of patients with Complex Regional
Pain Syndrome. BRAIN BEHAV IMMUN 2007; 21: 668-76 (filed as Ex. 43; hereinafter referred to as Ex. 43).
43
  Goebel A. Complex regional pain syndrome in adults. RHEUMATOLOGY 2011; 50: 1739-50 (filed as Ex.
56; hereinafter referred to as Ex. 56).
44
  Bruehl S. An Update on the Pathophysiology of Complex Regional Pain Syndrome. ANESTHESIOLOGY
2010; 113(3): 713-25 (filed as Ex. 55; hereinafter referred to as Ex. 55).

 Bilić E, et al. Complex Regional Pain Syndrome Type I after Diphtheria-Tetanus (Di-Te) Vaccination.
45

COLL ANTROPOL 2013; 37(3): 1015-18 (filed as Ex. 58; hereinafter referred to as Ex. 58).
46
   Kwun BS, et al. Complex regional pain syndrome by vaccination: A case of complex regional pain
syndrome after vaccination of influenza A(H1N1). PEDIATR INT 2012; 54: e4-e6 (filed as Ex. 59; hereinafter
referred to as Ex. 59).
47
  Richards S, et al. Complex regional pain syndrome following immunization. ARCH DIS CHILD 2012; 97:
913-15 (filed as Ex. 60; hereinafter referred to as Ex. 60).
48
   Genc H, et al. Complex regional pain syndrome type-I after rubella vaccine. EUR J PAIN 2005; 9: 517-20
(filed as Ex. 62; hereinafter referred to as Ex. 62).
49
 Schwartzman RJ, Erwin KL, Alexander GM. The Natural History of Complex Regional Pain Syndrome.
CLIN J PAIN 2009; 25(4): 273-80 (filed as Ex. 41; hereinafter referred to as Ex. 41).


                                                   39
However, during his testimony, Dr. Aradillas displayed apparent gaps in knowledge that
undermined his overall opinion. There are several examples, below, from the hearing. At the
beginning of cross examination, Respondent’s counsel asked Dr. Aradillas a series of questions
about Petitioner’s initial signs50 of CRPS:

        Q: What do you believe was the first objective sign of Ms. Dixon-Jones’ CRPS?

        A: It was probably the allodynia that -- the pain she reported to touch later on on
        her face, a month later when she reported that she hurt to touch. That would be the
        first sign of CRPS, I would think.

        …

        Q: So, Doctor, will you take a second to refresh your recollection and show me
        where the objective sign that you’re referencing is documented.

        A: It’s here on the body of the history of present illness. The -- Ms. Dixon-Jones
        states that the pain was piercing, which was worsened if she touches anywhere
        around her ear.

Tr. at 137-38.

       Eventually, Dr. Aradillas acknowledged there was no sign documented in the medical
records of facial pain or ear pain. See Tr. at 139. Respondent’s counsel continued with this line
of questioning:

        Q: So at Exhibit 18, page 7, is Dr. Sellman’s February 17th, 2017 [sic], notes of that
        visit on February 17, 2012, and where there do you see an objective sign of CRPS?

        A: Here, under the cranial function, the last paragraph, it says, “She complained
        that she was having diffuse pain throughout her entire body from her fibromyalgia.”

Tr. at 141.

        Although Dr. Aradillas did provide accurate definitions of symptoms and signs when asked
to do so on cross examination and eventually testified that walking slowly and exhibiting decreased
range of motion were signs, his repeated confusion of the difference between signs and symptoms
caused me to give less weight to his testimony than to that of Dr. Low.

        Dr. Aradillas also testified extensively about Petitioner’s pre-CRPS medical history, and
how he could distinguish between her pre-existing pain, and her pain associated with CRPS.
Petitioner visited Harbor Pain Associates on October 14, 2009 and filled out a patient
questionnaire. See Ex. 13 at 38. Harbor Pain Associates completed a new patient evaluation on

50
   A sign is defined as “an indication of the existence of something; any objective evidence of a disease,
i.e., such evidence as is perceptible to the examining physician, as opposed to the subjective sensations
(symptoms) of the patient.” Dorland’s at 1708.

                                                   40
October 16, 2009. See Ex. 13 at 32. Dr. Aradillas testified about both of these documents. He
first discussed the new patient evaluation (Ex. 13 at 32).

        Q: How does this medical history help with your assessment of Ms. Dixon-Jones’
        diagnosis?

        A: Well, you can see here that it is the first time that she went to [a] pain doctor for
        her chronic pain. … Yes, this particular pain doctor. And she was only complaining
        of it seems like pain in the mid and low back, and she described it as an occasional
        burning sensation in the mid[-]back that radiates laterally on the right side, and she
        also says that she takes for it Lyrica at bedtime, as needed.

Tr. at 93.

        He next discussed the significance of the questionnaire (Ex. 13 at 38):

        Q: So this is a patient questionnaire, and what can you learn from looking at Exhibit
        -- at page 38 here? This was filled out by Mrs. Dixon-Jones.

        A: Well, you can see that the only region in her body that she marked as painful
        was right down here is in the low back. She didn’t mark anything on the -- going
        down the legs. She didn’t mark anything on her arms. It was just basically
        restricted to the low back.

Tr. at 94.

        Dr. Aradillas’ summary of these two records is not complete. Further, his conclusion that
Petitioner did not suffer any pain from her back that radiated to her legs in the 2009 timeframe is
inaccurate. When he summarized the new patient evaluation in his testimony, Dr. Aradillas left
out one key sentence. The relevant portion of that document reads as follows:

        She describes occasional burning sensation in the mid back area that radiates
        laterally on the right side. She also describes an achy sensation in the low back
        that radiates into her right buttock as well as her right thigh. She takes
        Excedrin PM as needed as well as Lyrica 75 mg at bedtime as needed.

Ex. 13 at 32 (emphasis added). In summarizing the record in his testimony, Dr. Aradillas left out
the sentence bolded above. He testified to the sentence before and after but made no mention of
pain radiating from the back to the buttock and thigh. See Tr. at 93. Then he went on to testify
that Petitioner did not mention pain going into her legs in the questionnaire, leaving the impression
that there was no pain radiating into her legs in 2009. This incomplete and inaccurate testimony
concerning Petitioner’s pre-vaccination medical history was an additional factor that caused me to
place less weight on his testimony as compared to that of Dr. Low.

       Finally, I found Dr. Low to be the more credentialed expert witness. He is a professor of
neurology at the Mayo Clinic with a named chair. He has been board certified in neurology for

                                                  41
nearly 40 years, and during that time, has both seen patients and conducted research. In short, Dr.
Low’s testimony was extremely helpful to me in the resolution of this case and I gave it more
weight than I did the testimony of Dr. Aradillas.

     C. Petitioner has not Carried her Burden of Proof

       1. There is not Preponderant Evidence that Petitioner Suffers from CRPS

        The first step in an “off-Table” claim is to “determine what injury, if any, was supported
by the evidence presented in the record.” Lombardi v. Sec’y of Health & Human Servs., 656 F.3d
1343, 1353 (Fed. Cir. 2011). The Vaccine Act “places the burden on the petitioner to make a
showing of at least one defined and recognized injury,” and “[i]n the absence of a showing of the
very existence of any specific injury[,] . . . the question of causation is not reached.” Id.; see
Broekelschen, 618 F.3d at 1346 (explaining that “identifying the injury is a prerequisite to the
[causation] analysis”). In this case, Petitioner has not demonstrated that she suffered from CRPS.

         In order to be diagnosed with CRPS, a patient must have continuing pain disproportionate
to any inciting event, display the signs and symptoms enumerated in the Budapest Criteria, and
establish that no other diagnosis better explains the patient’s signs and symptoms. Dr. Low
testified that he believes Petitioner was correctly diagnosed with fibromyalgia and that her
fibromyalgia explains her symptoms. Tr. at 220. For the reasons outlined below, I agree with Dr.
Low’s assessment and find that Petitioner was correctly diagnosed with fibromyalgia by her
treating rheumatologist, Dr. Nasseri.

               a. Petitioner’s Fibromyalgia Diagnosis is Supported by the Record

        Ms. Dixon-Jones was diagnosed with fibromyalgia in 2006. Ex. 3 at 6. However, the
records from this timeframe are unavailable. Petitioner’s visit to Dr. Nasseri on February 14, 2013
references this fact, and notes that she has been a patient of the Arthritic & Rheumatic Clinic but
has not been seen in several years. Id. During this visit in February of 2013, Petitioner was
assessed as having “numerous tender points on trunk, and upper and lower extremities” as well as
pain in her joints located at multiple sites. Id. at 7. Dr. Nasseri believed that “it [was] likely her
symptoms which also include numerous trigger points on upper and lower extremities are a flare
of her previously diagnosed fibromyalgia.” Id.

       On March 20, 2013, Ms. Dixon-Jones followed up with Dr. Nasseri complaining of
“shoulder pain and burning sensation in her bilateral thighs.” Ex. 3 at 1. She also stated that she
has headaches in the occipital area on a daily basis. Id. Dr. Nasseri again noted “numerous tender
points on trunk, and upper and lower extremities.” Id. at 4. He reiterated his belief that her
symptoms “are an exacerbation of her previously diagnosed fibromyalgia […] [and] that her
fibromyalgia is very severe.” Id.

       Petitioner filed an article by Wolfe et al. entitled The American College of Rheumatology
Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Ex.
71. In it, the authors state that a patient satisfies the diagnostic criteria for fibromyalgia if the
following three conditions are met:

                                                 42
           (1)     Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5
                   or WPI 3-6 and SS scale score ≥9.
           (2)     Symptoms have been present at a similar level for at least 3 months.
           (3)     The patient does not have a disorder that would otherwise explain the pain.

Ex. 71 at 8.

        The WPI is calculated by adding one point for each area in which the patient has
experienced pain over the past week. Because there are 19 possible areas of pain, a patient’s WPI
score will be between zero and 19.51 Id. The SS scale score is calculated by first assigning points
based on the severity of a patient’s symptoms in three categories (fatigue, waking unrefreshed, and
cognitive symptoms). A patient is assigned between zero and three points in each category for a
maximum of nine points. Id. Then, between zero and three points are also assigned based on the
severity of somatic symptoms.52 Id. These two totals are added together and constitute the SS
scale score, a number between zero and 12. Id.

         Dr. Aradillas testified at hearing that the diagnostic criteria for fibromyalgia were
developed in 2010. Tr. at 107-08. He makes the point that when Petitioner was first diagnosed
with fibromyalgia in 2006, those criteria were not yet in use. He suggests that her 2006 diagnosis
was made in error through the use of an outdated standard. In support of this opinion, Dr. Aradillas
testified that Petitioner’s medical records suggest that she had pain only in her arms, which was
explained by carpal tunnel syndrome and radial nerve compression. Id. at 108.

       There is not enough evidence to support or rebut the contention that Petitioner’s 2006
fibromyalgia diagnosis was not in accordance with the 2010 diagnostic criteria, as the medical
records pertaining to this diagnosis have not been filed. However, it is clear that when Dr. Nasseri
evaluated Petitioner in February and March of 2013, the new and accepted criteria were in place,
and that during these visits, Dr. Nasseri reaffirmed Petitioner’s diagnosis of fibromyalgia.53




51
  The areas of pain include: left shoulder girdle, right shoulder girdle, left upper arm, right upper arm, left
lower arm, right lower arm, left hip (buttock, trochanter), right hip (buttock, trochanter), left upper leg, right
upper leg, left lower leg, right lower leg, left jaw, right jaw, chest, abdomen, upper back, lower back neck.
Ex. 17 at 8.
52
   Possible somatic symptoms listed in the diagnostic criteria include: muscle pain, irritable bowel
syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps
in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper
abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing,
Raynaud’s phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in
taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy
bruising, hair loss, frequent urination, painful urination, and bladder spasms. Ex. 71 at 8.
53
     Dr. Aradillas did not discuss Petitioner’s 2013 fibromyalgia diagnosis during his testimony at hearing.


                                                        43
         After conducting a careful review of the medical records, I find that Dr. Nasseri’s
evaluation of Petitioner is thorough and appears to be consistent with fibromyalgia’s diagnostic
criteria. Because he is one of Petitioner’s treating physicians, I give substantial weight and
deference to Dr. Nasseri’s opinion. I have no reason to question his diagnosis, especially when it
is supported by Petitioner’s own complaints, as documented in her contemporaneous medical
records.54 Further, there is no reason to believe that Dr. Nasseri, who is a rheumatologist, was
unaware of the diagnostic criteria for fibromyalgia, or that he somehow incorrectly calculated the
WPI or SS scale score or misapplied the diagnostic criteria in arriving at Petitioner’s diagnosis.

        Dr. Low credited Dr. Nasseri’s examinations as “superb” and agreed that Petitioner’s
correct diagnosis is fibromyalgia. Tr. at 177. He enumerated several factors to support this
opinion. Dr. Low testified that Petitioner’s chronic fatigue, as well as the existence of numerous
trigger points, identified and later injected by Dr. Nasseri, are both “very characteristic of
fibromyalgia.” Id. Dr. Low also discussed the waxing and waning nature of Petitioner’s illness
as being consistent with fibromyalgia and not with CRPS. Id. at 175. Further, Petitioner’s medical
records describe all over pain (as opposed to pain in a limb or impacting a region of her body).
Dr. Low testified that “diffuse pain with trigger points is much more consistent with fibromyalgia
than CRPS.” Id. at 183.

        I credit the opinions of Dr. Nasseri and Dr. Low over Dr. Aradillas. Petitioner was properly
diagnosed with fibromyalgia, and she does not meet the diagnostic criteria for CRPS, which
require no other diagnosis that better explains her signs and symptoms.

                b. Petitioner Experienced Many Other Painful Conditions

        In addition to fibromyalgia, Petitioner also experienced many other conditions, both painful
and non-painful. A non-exhaustive list of these conditions includes: carpal tunnel syndrome,
asthma, hypertension, hypothyroidism, pancreatitis, brachial plexopathy, gastroesophageal reflux
disease, cholelithiasis, gastritis, uterine fibroids, chronic fatigue, chronic pain syndrome, ovarian
cyst, disc herniation, lumbago, cervicalgia, myofascial pain syndrome, vertigo, cyclical vomiting

54
   Dr. Nasseri repeatedly referenced “numerous trigger points” in Petitioner’s trunk and upper and lower
extremities. Ex. 3 at 4, 7. The records from these rheumatology visits also list a number of the somatic
symptoms enumerated in Ex. 71, to include: headaches (Ex. 3 at 1), depression (Ex. 3 at 2 under “past
medical history”), rash (Ex. 3 at 6), insomnia (Ex. 3 at 7 under “past medical history”), tingling and
numbness (Ex. 3 at 8 under “review of symptoms”), fatigue (Ex. 3 at 7 under “past medical history”),
heartburn (Ex. 3 at 7 listed as “acid reflux” under “past medical history”), and wheezing (Ex. 3 at 7, asthma
listed under “past medical history”). Because MiraLax is listed as a current medication (Ex. 3 at 1, under
“current medications”), this also suggests that Petitioner suffers from constipation, another somatic
symptom of fibromyalgia. In addition, Petitioner’s medical records from close-in-time to these
rheumatology visits also mention other somatic symptoms listed in Ex. 71. In September and November of
2012, Petitioner saw various doctors concerning thinking or remembering problems (See Ex. 10 at 21,
September 17, 2012 visit to rule out Alzheimer’s disease; Ex. 24 at 13, November 19, 2012 visit where
doctor noted evidence of cognitive dysfunction). On February 19, 2013, Petitioner saw an optometrist and
reported symptoms of ringing in ears (tinnitus), muscle aches, and blurred vision (Ex. 2 at 12-13). She
sought treatment on March 3, 2013 for chest pain, abdominal pain, and purported seizures (Ex. 10 at 9).
On September 13, 2012, Ms. Dixon Jones also complained of sleep difficulty and not feeling refreshed
when she wakes (Ex. 24 at 10).

                                                     44
syndrome, memory loss, chest pain, insomnia, significant slowing in the posterior area of the
cortex, recurrent rash, headaches, and bilateral shoulder adhesive capsulitis. Petitioner has also
complained of seizures, PTSD after an epidural, PRES, brain swelling after flu vaccine, and
sphincter of Oddi dysfunction. Petitioner’s medical history, both before and after vaccination is
extensive and complex. This involved medical history makes it difficult for Petitioner to establish
that her pain was caused by vaccination, and further that no other diagnosis better explains her
signs and symptoms.

        Dr. Aradillas attempted to address this issue by attributing Petitioner’s pain post-
vaccination to the amplification of her pre-existing pain through the central sensitization process.
Tr. at 128. I find Dr. Aradillas’ explanation to be unpersuasive for the reasons discussed later in
this decision.55

                c. Petitioner’s Medical Record Evidence Does Not Support a CRPS Diagnosis

                         (i) Petitioner did not have Regional Pain

        As stated in the diagnostic criteria, CRPS is a disease that is typically regional in nature,
impacting one or more limbs. “CRPS describes an array of painful conditions that are
characterized by continuing regional pain that is seemingly disproportionate in time or degree to
the usual course of any known trauma or other lesion.” Ex. C at 1. In an article that he co-authored,
Dr. Low writes that CRPS “is best considered a type of chronic limb pain with certain specific
characteristics.” Ex. F at 1. During the hearing, Dr. Low described regional pain as “outside of
the distribution of one or two peripheral nerves. It’s usually in a region of the body, such as an
arm or a leg.” Tr. at 171. In fact, numerous articles and case reports cited by Petitioner confirm




55
  Dr. Aradillas highlighted Petitioner’s “new” pain radiating down to her right and left knees and her
buttocks as “another example of how her old pains are starting to amplify because of the central sensitization
process.” Tr. at 130. As discussed supra, this is a mischaracterization of the medical record; Petitioner
did, in fact have pain that radiated from her lower back into her legs in 2009.


                                                     45
this point.56,57,58,59,60,61,62,63

        With respect to Petitioner, Dr. Aradillas testified that her initial sign and symptom of CRPS
was facial pain, specifically pain around her ear. Tr. at 137-38. However, when asked to define
Petitioner’s region of pain, Dr. Aradillas testified as follows:

         Q: So what are – what is Ms. Dixon-Jones’ region of pain at the onset of her CRPS?

         A: The – from what I read among the records, it was an exacerbation of her previous
         pains. The region of pain that it went to, it was her left buttock, right buttock, all
         the way down to knees – to the knees bilaterally.


56
  Goebel A, et al. Intravenous Immunoglobulin Treatment of Complex Regional Pain Syndrome. ANN
INTERN MED 2010; 152(3): 152-8 (filed as Ex. 49; hereinafter referred to as Ex. 49)(CRPS “is a painful,
usually posttraumatic condition in a limb”).
57
   Kohr D, et al. Autoimmunity against β2 adrenergic receptor and muscarinic-2 receptor in complex
regional pain syndrome. PAIN 2011; 152: 2690-2700 (filed as Ex. 50; hereinafter referred to as Ex. 50)(“The
main clinical features are pain and hyperalgesia, vasomotor, pseudomotor, and trophic changes in the
affected limb”).
58
  Blaes F, et al. Improvement of complex regional pain syndrome after plasmapheresis. EUR J PAIN 2015;
19: 503-7 (filed as Ex. 51; hereinafter referred to as Ex. 51)(“Complex regional pain syndrome is a severe
complication following trauma that is associated with vasomotor, sudomotor and sensory disturbances in
an affected limb or region of the body”).
59
  Goebel A, Blaes F. Complex regional pain syndrome, prototype of a novel kind of autoimmune disease.
AUTOIMMUN REV 2013; 12: 682-6 (filed as Ex. 52; hereinafter referred to as Ex. 52)(“Complex regional
pain syndrome (CRPS) is a painful condition, which arises in a limb after trauma.
60
   Goebel A, et al. The passive transfer of immunoglobulin G serum antibodies from patients with
longstanding Complex Regional Pain Syndrome. EUR J PAIN 2011; 15: 504.e1-504.e6 (filed as Ex. 61;
hereinafter referred to as Ex. 61)(“Complex regional pain syndrome (CRPS) is usually posttraumatic and
restricted to one limb”).
61
   Siegal SM, Lee JW, Oaklander AL. Needlestick Distal Nerve Injury in Rats Models Symptoms of
Complex Regional Pain Syndrome. ANESTH ANALG 2007; 105(6): 1820-9 (filed as Ex. 68; hereinafter
referred to as Ex. 68)(“Complex regional pain syndrome (CRPS)-I consists of chronic limb pain.…”).
62
   Jastaniah WA, et al. Complex regional pain syndrome after Hepatitis B vaccine. J PEDIATR 2003; 143:
802-4 (filed as Ex. 73; hereinafter referred to as Ex. 73)(“Complex regional pain syndrome (CRPS) type I
is a disorder of one or more extremities.…”).
63
  See also Ex. 55 at 1 (CRPS “typically develops in an extremity after acute tissue trauma”); Ex. 56 at 1
(“Complex regional pain syndrome (CRPS) is a painful condition that develops after trauma to a limb”);
Ex. 58 at 1 (“Complex regional pain syndrome type I (CRPS I) is a disorder of one or more extremities.…”);
Ex. 60 at 1 (“Complex regional pain syndrome type I (CRPS I) is a clinical syndrome that affects one or
more extremities.…”); Ex. 62 at 1 (“Complex regional pain syndrome type I (CRPS-I) is a complex clinical
disorder of one or more extremities.…”).

                                                    46
       Q: So as I understand that criteria, the regional pain is where it starts, right, so the
       CRPS where you’re going to have your first sign or symptom. So isn’t it true, like,
       typically in CRPS someone will walk in and it’s a limb and it’s generally affected?

       A: It is – that is true, yeah.

       Q: Okay. So I’m asking you, what is the region of pain that her diagnosis started?
       And you’re saying it was her left side, her left leg and buttock?

       A: Left and right buttocks and left and right legs. It radiated – her pain radiated
       down there.

       …

       Q: So you think facial pain is a first symptom, but her region of pain, according to
       the Budapest criteria, is her left and right legs?

       A: Yes.

Tr. at 142-44. As noted supra, the medical literature consistently describes CRPS as a regional
disorder impacting one or more limbs. Dr. Aradillas’ description of Petitioner’s initial symptom
of CRPS as facial pain, while relating her region of pain was her left and right buttocks and left
and right legs, is not consistent with the description of CRPS cited in much of Petitioner’s medical
literature.

        As evidenced throughout her post-October 6, 2011 flu vaccination medical records,
Petitioner’s pain was not regional in nature impacting one or more limbs. Instead, Petitioner’s pain
is best characterized as diffuse and/or widespread impacting different parts of her body.
Sometimes this included pain to the extremities, but often it did not. Petitioner complained of ear
pain (Ex. 26 at 26, 27; Ex. 20 at 4) which also radiated into her left jaw (Ex. 12 at 24), abdominal
pain to include pain in the right and left upper quadrant (Ex. 11 at 8; Ex. 12 at 26; Ex. 12 at 37;
Ex. 16 at 23; Ex. 16 at 29; Ex. 16 at 36; Ex. 10 at 192), low back pain that radiated into her right
buttock, left buttock, right knee, and left knee (Ex. 16 at 23; Ex. 16 at 29; Ex. 16 at 34; Ex. 16 at
91; Ex. 33 at 3), mid-back pain (Ex. 16 at 29; Ex. 16 at 36; Ex. 33 at 3), pain in her feet and legs
(Ex. 16 at 29; Ex. 16 at 34; Ex. 16 at 91; Ex. 120 at 36), a generalized constant burning sensation
that migrated to different areas of her body (Ex. 27 at 32), arm pain (Ex. 26 at 27; Ex. 18 at 3; Ex.
24 at 9; Ex. 120 at 5), tingling and piercing sensation in random areas (Ex. 16 at 49), generalized
myalgias in the upper extremities (Ex. 24 at 2), shoulder pain (Ex. 3 at 6; Ex. 3 at 1; Ex. 16 at 91;
Ex. 127 at 32; Ex. 17 at 13), thigh pain (Ex. 3 at 6; Ex. 3 at 1), hip pain (Ex. 16 at 91), and hand
pain (Ex. 127 at 32; Ex. 127 at 15).

       As Dr. Low discussed in his testimony, this type of widespread migratory pain is not
characteristic of CRPS but is consistent with fibromyalgia. See Tr. at 183.

                       (ii) Petitioner did not Experience Unrelenting, Persistent Pain and/or Other
                       Symptoms

                                                 47
       Dr. Low described the pain associated with CRPS during his testimony, stating that it “is
unrelenting, simply doesn’t change. It doesn’t change from day to day. The patient isn’t going to
come in and see one physician and have a normal exam and the next day have severe abnormalities
as noted by someone else.” Tr. at 171-72. Dr. Low clarified that in addition to the pain associated
with CRPS, the other signs such as skin color changes and edema also do not fluctuate. Id. at 218-
19. He further testified as follows:

        Q: Does the pain in the initial region subside with CRPS?

        A: It doesn’t change very much from day to day, and it never goes away unless the
        condition improves.

        Q: Is there a waxing and waning course to CRPS?

        A: Not – not typically, unlike, say, fibromyalgia, where they get periods of
        improvement and periods of worsening. With CRPS, you don’t. If one physician
        sees it, the next physician should see it.

Tr. at 175. In fact, the medical literature filed in this case supports this concept. In an article by
Alexander et al., the authors state, “[t]he pain in CRPS is continuous, it worsens over time…” See
Ex. 43. Schwartzman et al. studied the evolution of CRPS signs and symptoms. See Ex. 41. Dr.
Low referred to this article in support of his testimony regarding the unrelenting nature of CRPS
pain. Specifically, he highlighted figure 2:




 FIGURE 2. Variations in the intensity of overall pain on a 0 to 10
 numerical rating scale versus duration of disease. The intensity of
 overall pain demonstrated a statistically significant positive
 correlation with progression of disease (r = 0.60, P = 0.005).


Ex. 41 at 3. Dr. Low testified that figure 2 demonstrates CRPS patients have severe pain, the pain
increases over time, and the pain is unrelenting “and does not change from moment to moment.”

                                                           48
Tr. at 199-200. Dr. Aradillas also agreed that the pain associated with CRPS is not intermittent.
Id. at 96, 100-01.

        Dr. Aradillas testified that the start of Petitioner’s CRPS was her left ear pain. “The pain
was piercing, worse if she touches anywhere around the ear, so that is definitely what you would
call allodynia, a nonpainful stimulus, just touch is perceived as painful. So that tells me that at
that time, the central sensitization process was starting … to happen.” Tr. at 126.

        Petitioner reported ear pain at medical visits on October 12, 2011 (Ex. 26 at 27), October
26, 2011 (Ex. 26 at 26), and November 2, 2011 (Ex. 12 at 24). During her November 4, 2011
medical appointment with Dr. Schneyer, Petitioner reported ear pain since receiving her flu shot.
She stated that “[i]t occurred intermittently every few days up to last Friday. Since then she has
not had any piercing ear pain. She is taking Dilaudid for pain, but she thinks the pain just dissipates
on its own.” Ex. 20 at 4. Petitioner’s ear pain, described by Dr. Aradillas as indicating the start of
the central sensitization process, went away in early November 2011. This is not consistent with
Dr. Low’s description of pain associated with CRPS.

        Petitioner has also experienced abdominal pain since at least 2003. During his testimony,
Dr. Aradillas discussed Petitioner’s burning, band-like abdominal pain as indicative of CRPS. On
July 21, 2014, Petitioner followed up with Dr. Pasricha for her symptoms of chronic nausea,
GERD, and left upper quadrant abdominal pain. Ex. 14 at 7. During this visit, Petitioner
experienced no epigastric pain, and her abdominal pain was described as “intermittent” and
“mainly post-prandial and crampy in nature.” Id. at 7, 12. This type of intermittent pain is not
consistent with Dr. Low’s description of pain associated with CRPS.

        At various medical visits, Petitioner has described her pain as both migratory and at times,
intermittent. For example, on February 17, 2012, Petitioner complained that she was having
“diffuse pain throughout her entire body from her fibromyalgia.” Ex. 18 at 7. On April 18, 2012,
Petitioner stated that her pain was a “constant burning sensation that migrates to different areas of
her body.” Ex. 27 at 32. On May 7, 2012 she reported “tingling and piercing sensation in random
areas.” Ex. 16 at 49. On February 14, 2013, Petitioner described “intermittent burning pain in her
bilateral shoulders, thighs, or knees.” Ex. 3 at 6. Dr. Low opined that these various descriptions
are common symptoms seen in fibromyalgia and are not characteristic of CRPS. See Tr. at 171-
72, 175, 183.

        In addition to CRPS pain being characterized as unrelenting, Dr. Low also described the
other signs of the disease, such as swelling and redness as remaining constant. See Tr. at 218-19.

        On June 17, 2013, Petitioner visited Dr. Williams complaining of bilateral upper extremity
pain and weakness. Dr. Williams noted upon inspection of her left and right upper extremities that
there was “no erythema, induration, swelling, warmth, mass or scars normal appearance and
normal bulk and tone with no wasting.” Ex. 127 at 32. “Vascular right” and “vascular left” both
state, “normal color and temperature”. Id. at 33. Petitioner followed up with Dr. Williams on
September 30, 2013, March 31, 2014, May 27, 2014, and August 21, 2014. (See Ex. 127 at 29,
25-26, 22, 18). Each time, Dr. Williams made consistent annotations regarding redness, swelling,
warmth, color, and temperature. In fact, the annotations are identical, except that the visits on

                                                  49
March 31, 2014, May 27, 2014, and August 21, 2014 under inspection left and inspection right
state “no erythema, induration, swelling, warmth, or mass” whereas on June 17, 2013 and
September 30, 2013, they state, “no erythema, induration, swelling, warmth, mass or scars normal
appearance and normal bulk and tone with no wasting.” The vascular annotations are identical.

       Petitioner visited Dr. Aradillas on October 13, 2014. Dr. Aradillas noted “[e]rythema of
the shoulders and supraclavicular fossa, there was also swelling specially [sic] at the right arm
throughout but evident at the hand and forearm along with a purplish discoloration of both hands.”
Ex. 23 at 7.

        On December 4, 2014, Petitioner followed up with Dr. Williams. Dr. Williams again noted
in the inspection of her right and left extremities “no erythema, induration, swelling, warmth, or
mass.” Ex. 127 at 14. He also noted (as in each of his previous examinations) under “vascular
right” and “vascular left” that Petitioner had “normal color and temperature”. Id. Dr. Williams
performed similar examinations on March 16, 2015 and July 13, 2015 with identical findings. See
Ex. 127 at 9-10, 5.

        Petitioner had no swelling or color changes during any of her visits with Dr. Williams,
which occurred both before and after her visit with Dr. Aradillas. The apparent change in
Petitioner’s color and swelling of her upper extremities are not consistent with CRPS as described
by Dr. Low.

                         (iii) Petitioner’s Bone Scan Results do not Support a CRPS Diagnosis

        Dr. Low testified about the three-phase bone scan as a helpful test in either including or
excluding CRPS as a diagnosis. See Tr. at 192-94. While a negative test does not eliminate the
possibility that the patient has CRPS, it reduces the likelihood of CRPS if the test is normal. Id. at
194. In an epidemiologic study that he supervised, Dr. Low and the authors reviewed a group of
patients who had been diagnosed with CRPS. In that study, a subset of those patients had a three-
phase bone scan. Approximately 85 percent of those tested had an abnormal scan, which “showed
a pattern consistent with the diagnosis of CRPS.” Ex. F at 3. A similar percent also had abnormal
autonomic function tests. See Ex. F; Tr. at 192. Dr. Low went on to testify regarding bone scan
testing that “[i]f you looked at all the data, it had a sensitivity and a specificity64 of over 80 percent.
Tr. at 193.

        Dr. Nasseri, Petitioner’s treating rheumatologist, ordered a whole-body bone scan to
evaluate Petitioner for CRPS. Ex. 11 at 41. The results of the examination concluded that
Petitioner had “[n]o scintigraphic evidence of reflex sympathetic dystrophy.” Id.

      The negative results of Petitioner’s bone scan do not completely exclude a CRPS diagnosis.
However, they provide solid and objective support for Dr. Low’s opinion that Petitioner did not
have CRPS.

64
  Sensitivity reflects “the conditional probability that a person having a disease will be correctly identified
by a clinical test.” Dorland’s at 1692. Specificity reflects “the conditional probability that a person not
having a disease will be correctly identified by a clinical test.” Id. at 1742.


                                                      50
               d. The Opinions of Petitioner’s Treating Physicians

        Several of Petitioner’s treating doctors attributed her condition to her flu vaccination while
many others did not. Treating physicians are often entitled to deference because, having evaluated
their patient, they are able to determine whether “a logical sequence of cause and effect shows that
the vaccination was the reason for the injury.” Capizzano, 440 F.3d at 1326. In this case, the
opinions of treating physicians can be divided into several categories: 1) physicians who directly
attribute Petitioner’s symptoms to her flu vaccination; 2) physicians who recite the history
provided by Petitioner; and 3) physicians who do not attribute Petitioner’s symptoms to her flu
vaccination.

                       (i) Physicians who Attribute Petitioner’s Condition to her Vaccination

        Shortly after her vaccination, Petitioner experienced what she described as an allergic
reaction. At least one of her treating physicians commented on this reaction and linked it to her
recent flu vaccination. On October 12, 2011, Petitioner presented to her allergist, Dr. Mardiney,
who noted that, “last Thursday she had a flu vaccine administered at work. The injection was
given about 11:30 A.M. and at about 2 o’clock the right arm swelled. It stayed painful, but at 3:30
A.M. on Friday morning she woke up with extreme pain in the left ear, swelling of both hands,
facial rash and shortness of breath.” Ex. 26 at 27. By the time Petitioner presented to Dr.
Mardiney, she did not have any signs of allergic reaction. See Id. Dr. Mardiney diagnosed
Petitioner with “adverse response to flu vaccine, manifested by angioedema, as well as
bronchospasm, Eustachian tube dysfunction and skin rash.” Id. Other treating physicians have
noted Petitioner’s allergic reaction in subsequent records.

        While several of Petitioner’s treating physicians diagnose her with an allergic reaction to
the flu vaccine, Petitioner has alleged that the flu vaccine caused her to develop CRPS. As
discussed in more detail below, I do not find Petitioner’s theory, that an allergic reaction led to the
production of proinflammatory cytokines which in turn initiated the central sensitization process
and caused her to develop CRPS, to be supported by preponderant evidence. As a result, the
opinions of treating physicians who ascribe Petitioner’s allergic reaction to her flu vaccination do
not alter my analysis in this case.

         Other than Dr. Aradillas, the other treating physician who attributed Petitioner’s condition
to her flu vaccination is Dr. Kozachuk. Dr. Kozachuk, on the first day he treated Ms. Dixon-Jones,
found that her “physical symptoms of chronic pain and cognitive dysfunction show direct
causation to the accident of 10-6-11, and [that she] is totally and temporarily disabled.” Ex. 24 at
3-4. It is unclear how Dr. Kozechuk arrived at this conclusion, as he did not elaborate on his basis
for connection of the flu vaccine with Ms. Dixon-Jones’ symptoms. Dr. Kozachuk’s statements
regarding diagnosis are conclusory and do not appear to be supported by the medical records.
Accordingly, I do not find his assertions regarding the causality of the flu vaccine to be persuasive.

       As discussed earlier in this decision, Dr. Kozachuk was reprimanded by the Maryland
Medical Board and placed on probation for selling controlled substances in exchange for cash in
public places. His behavior was described by the Board as “a flagrant abandonment of

                                                  51
professionalism.” Although I did not base my evaluation of Dr. Kozachuk’s diagnosis on this
incident, the Board’s finding did not serve to buttress his opinion in this case.

                         (ii) Physicians who Recite the History Provided by Petitioner

       Petitioner’s records are replete with mention of her many prior conditions. For example,
PA Elisha Locke noted that Petitioner “has a history of CRPS in the left arm. She reported that
the symptoms in the left arm began after an influenza injection which later reportedly developed
CRPS.” Ex. 120 at 10. In this record, it appears that Petitioner provided PA Locke with a history,
and that history was entered into the record. As an additional example, the records from Dr.
Kramer (psychologist) listed Petitioner’s “problems/diagnoses” as “late effect of adverse effect of
drug, medicinal, or biological substance.” Ex. 27 at 30. Again, because Dr. Kramer is a
psychologist, it appears that he entered Petitioner’s history under the “problems/diagnoses” section
of the record. While I have considered the many records that contain this type of reference,
because they involve a recitation of medical history provided by Petitioner as opposed to a separate
assessment, they do not alter my analysis in this case.

                         (iii) Physicians who do not Attribute Petitioner’s Condition to her
                         Vaccination

        A number of Petitioner’s treating physicians specifically commented on the flu shot and
declined to provide a link between the vaccination and her symptoms. For example, Petitioner
visited Dr. Schneyer on November 11, 2011 with complaints of imbalance and dizziness. In
discussing the vaccination, Dr. Schneyer stated, “I explained to Mrs. Dixon-Jones that I did not
know what is causing her symptoms or why they started after her flow [sic] shot. However, her
inner ear seems to be functioning normally with a normal audiogram and ENG.” Ex. 20 at 2.

        Similarly, on December 19, 2011, Dr. Sellman noted that “it is speculative what event
occurred this fall to cause Mrs. Dixon Jones to intermittently have problems with memory loss as
well as vision and balance.” Ex. 18 at 16. In a later record, on April 26, 2012 Dr. Sellman stated,
“I spoke at great length today to Mrs. Dixon Jones and her husband, Melvin. I explained that I
have no experience in her specific allegations that she is having problems as a complication of the
flu shot.” Id. at 3. In context, this comment certainly does not attribute Petitioner’s symptoms to
her vaccination.65

        Importantly, except for Dr. Aradillas, none of Petitioner’s treating physicians diagnosed
her with CRPS. I have considered all the medical records in this case, to include statements by
Petitioner’s treating physicians in arriving at my determination.



65
   On March 14, 2012, Petitioner visited Dr. Sellman for evaluation of impaired memory which she
indicated was caused by her flu vaccination. In the notes from this visit, Dr. Sellman remarks upon an
inconsistency in Petitioner’s behavior. He writes, “She seems to be awake, alert, and responsive. She was
quite adamant on recent details with respect to days, dates, and times that she has called my office to verify
that I had her records. At the same time, she then explained to me that her memory was very poor with
respect to recent and long-term events.” Ex. 18 at 5-6.

                                                     52
         The Federal Circuit held in Broekelschen, 618 F.3d at 1346, that determining “causation
turns on which injury [petitioner] suffered.” The issue in that case was whether flu vaccine caused
Dr. Broekelschen transverse myelitis or anterior spinal artery syndrome. Id. at 1342. The special
master found respondent’s neurologic expert more credible than Petitioner’s expert, and thus
dismissed the case. Petitioner appealed on the basis that the special master first had to determine
if petitioner made a prima facie case of causation in fact and, only then, decide if respondent’s
known factor unrelated (anterior spinal artery syndrome) was the cause in fact of petitioner’s
condition. The Federal Circuit disagreed, stating “nearly all the evidence on causation was
dependent on the diagnosis of Dr. Broekelschen’s injury.” Id. at 1346.

        Based on the totality of the record, I find that Petitioner’s fibromyalgia diagnosis is
supported by the record, and her medical record evidence does not support a CRPS diagnosis. In
arriving at this determination, I have weighed the testimony of Dr. Low and Dr. Nasseri over that
of Dr. Aradillas and Dr. Kozachuk. I find there is not preponderant evidence that Petitioner has
CRPS.

     D. Althen Prongs

     Because Petitioner has not established that she had CRPS, further analysis is unnecessary.
However, for the sake of completeness, I will briefly analyze the Althen prongs.

       1. Althen Prong 1: There is not Preponderant Evidence that the Flu Vaccine Can Cause
          CRPS in the manner alleged by Petitioner in this case

        As described by extensive literature and confirmed by both experts, the exact mechanism
for onset of CRPS is yet unknown. Generally, CRPS can develop after a surgery, traumatic event,
or even a non-traumatic minor injury. Dr. Low testified that CRPS following needle stick, for
example, has been documented in literature. Tr. at 195.

        Petitioner’s theory of causation was multifaceted. Petitioner’s expert posited that
Petitioner’s CRPS developed not by needle stick, but rather from an inflammatory response
following her flu vaccination. According to Dr. Aradillas,

       the flu vaccine caused the normal activation of the innate system, causing
       increasing inflammatory cytokines to circulate, plus the vaccine also caused an
       allergic reaction, causing the degranulation of mast cells, which both together
       caused the permanent activation of microglia and astrocytes, glial cells surrounding
       the synapse of the pain transmission neurons, which led to this permanent
       glutamate-dependent neuroplasticity or central sensitization syndrome and
       manifested clinically as a worsening of her or amplified her old pains and the
       development of complex regional pain syndrome.

Tr. at 131. In support of this theory of causation, Petitioner presented several articles that explore
the involvement of inflammatory processes and mast-cell mediation as possible mechanisms
involved in CRPS.


                                                 53
         Petitioner’s theory of causation, however, was not supported by the literature. First, though
there is evidence to suggest that pro-inflammatory cytokines likely play a role in CRPS (although
it is not clear what that role is), heightened cytokine levels are not thought to be the initiating factor
for the development of CRPS. Instead, cytokine expression is part of the inflammatory
component66 of the acute phase of CRPS, which is triggered by tissue trauma or neuronal injury.
Ex. 82 at 3. In fact, literature stated that while the involvement of heightened cytokine expression
had been noted in patients already exhibiting CRPS, especially in the acute phase, “to date, no
human studies have directly evaluated the role of inflammatory factors in the onset of CRPS.” Ex.
55 at 6. Furthermore, it is continuously suggested that inflammation could be but one of many
mechanisms that, combined, “play a role in the pathophysiology of CRPS,”67 and that “local rather
than systemic inflammatory responses appear to be relevant in CRPS.” See Ex. 74 at 2. Therefore,
while the theory involving heightened cytokines in the initiation of CRPS may merit further
research, the state of literature at this time does not suggest that the systemic immune response
involved in vaccination can trigger nerve damage or neuronal injury and the subsequent complex
central sensitization process that eventually leads to CRPS.

        In addition to the above, I note special masters have found that general cytokine-based
theories of causation are not persuasive. Zumwalt on behalf of L.Z. v. Sec’y of Health & Human
Servs., No. 16-994V, 2019 WL 1953739, at *18 (Fed. Cl. Spec. Mstr. Mar. 21, 2019) (noting that
“[t]he fact that vaccines are known to stimulate cytokine production . . . does not amount to a
reliable causation theory that such stimulation is necessarily disease-causing”); Inamdar v. Sec’y
of Health & Human Servs., No. No. 15-1173V, 2019 WL 1160341, at *17 (Fed. Cl. Spec. Mstr.
Feb. 8, 2019) (noting that the proposition that vaccines can cause diseases by “induc[ing] the
production of proinflammatory cytokines . . . has several deficiencies”); McCabe v. Sec’y of Health
& Human Servs., No. 13-570V, 2018 WL 3029175, at *47-55 (Fed. Cl. Spec. Mstr. May 17, 2018);
McGuire v. Sec’y of Health & Human Servs., No. 10-609V, 2015 WL 6150598 at *12-18 (Fed.
Cl. Spec. Mstr. Sep. 18, 2015) (noting that the petitioner had failed to introduce “persuasive
evidence to rebut the IOM’s conclusion that no evidence supports a conclusion that cytokines
cause a disease”).

        Second, Petitioner’s presentation of literature exploring an involvement of mast cells does
not indicate that mast cells are involved in the development of CRPS. Rather, literature presented
supports the involvement of mast cells “in the pathophysiology of inflammation in CRPS,”


66
   Literature filed by Petitioner suggests that chronic regional and neurogenic inflammation may be key
components in the initiation of CRPS. See Goh EL, Chidambaram S, Ma D. Complex regional pain
syndrome: a recent update. BURNS TRAUMA 2017; 5:2 (filed as Ex. 82; hereinafter referred to as Ex. 82).
This theory led to the use of anti-cancer drugs, lenalidomide and thalidomide, in CRPS pain treatment. Id.
at 6. Though treatment efforts showed initial promise, phase IIb trial of lenalidomide failed “to show any
benefit over the placebo.” Id. Still, the exploration of immunomodulatory treatments and the role of
neurogenic inflammation as an initiating event of CRPS fails to provide support for the flu vaccine’s ability
to trigger chronic regional or neurogenic inflammation.
67
  Dirckx M, et al. Mast Cells: A New Target in the Treatment of Complex Regional Pain Syndrome? PAIN
PRACT 2013; 13(8): 599-603 (filed as Ex. 74; hereinafter referred to as Ex. 74).


                                                     54
specifically, in the acute phase.68 Ex. 74 at 1; see also 76 at 7. As such, mast cells are believed to
be involved as part of the ongoing inflammatory components of numerous neurodegenerative
diseases. See Ex. 74. Though the role of mast cells in the manifestation of pain and inflammation
has been documented, mast cell expression triggered by allergic reaction has not been identified
as a mechanism by which chemical stimulation of nociceptors resembles the tissue damage or
nerve injury involved in the initiation of CRPS. Thus, mast cell involvement has not been
recognized as a causative factor for CRPS. See generally Ex. 76.

       Finally, Petitioner has not demonstrated that the flu vaccination, combined with a
subsequent allergic reaction, can cause a reaction such that specific targeting of nociception can
occur. Consequently, Petitioner cannot illustrate through literature that such a localized reaction
can mirror that of a noxious or traumatic event, one that leads to the repetitive stimulation of nerve
endings as a result of tissue damage or nerve injury and contributes to the central sensitization
process.

       Accordingly, I do not find that Petitioner has met her burden in providing a theory of
causation linking the flu vaccination to CRPS. The literature does not support the development of
CRPS following an inflammatory or allergic event incited by vaccination, but rather suggests only
that components of inflammatory processes are involved in the expression CRPS and its numerous
symptoms.

       2. Althen Prong 2: There is not Preponderant Evidence that the Flu Vaccine Did Cause
          CRPS in Petitioner’s Case


       As discussed above, Petitioner did not meet her burden in providing evidence that
vaccination did cause her CRPS because I find that 1) Petitioner cannot establish that she has
CRPS, and 2) Petitioner cannot establish that flu vaccination can cause CRPS.

         First, in order to prove that the vaccination Petitioner received on October 6, 2011 caused
CRPS, Petitioner must establish that she has CRPS, which in this case she failed so to do.
Petitioner was not able to show that her post-vaccination symptom presentation met the diagnostic
criteria for CRPS, was labeled as CRPS by her treating physicians, or was not better explained by
a diagnosis of fibromyalgia. For example, Petitioner’s pain was not regional in nature but rather
diffuse, spread throughout her entire body. Similarly, Petitioner did not present with the
unrelenting pain characteristic of CRPS. Petitioner’s pain symptoms waxed and waned in both
duration and presentation. In particular, Petitioner presented to Dr. Aradillas in October 2014 with
erythema of the shoulders, swelling of the right arm, and discoloration of both hands, signs which
contributed to his diagnosis of CRPS. However, at eight appointments with Dr. Williams, both
before and after October 2014, the visit records indicate that Petitioner did not exhibit these signs.
Both experts confirmed that intermittent presentation of signs and symptoms was uncharacteristic
of CRPS.


68
  Aich A, Afrin LB, Gupta K. Mast Cell-Mediated Mechanisms of Nociception. INT J MOL SCI 2015; 16:
29069-92 (filed as Ex. 76; hereinafter referred to as Ex. 76).


                                                 55
       As I stated above, I find that Petitioner’s signs and symptoms were better explained by a
diagnosis of fibromyalgia. Petitioner’s widespread pain, waxing and waning symptoms, and
ongoing presentation of numerous somatic symptoms were described as characteristic of
fibromyalgia. Further, I find that Dr. Nasseri’s examination leading to Petitioner’s diagnosis was
thorough and in keeping with the current diagnostic standard.

        In addition to failing to establish that she had CRPS, Petitioner also failed to establish that
the flu vaccination can cause CRPS. Petitioner’s theory of causation was based on the general
process behind central sensitization, observed in many neuropathies. Petitioner was not able to
demonstrate that this process could be triggered or altered by a flu vaccination or an allergic
reaction to a flu vaccination. Even so, several factors anchoring Petitioner’s own theory were not
present in Petitioner’s medical testing.

        First, Petitioner’s theory relied on heightened cytokine response to the vaccination and
during the alleged reaction to the vaccination. Petitioner presented literature discussing the
pathophysiologic mechanisms of CRPS and the role that cytokine expression may serve, as one of
the multiple mechanisms usually involved. Ex. 55 at 2. Clinical trials have indicated that
corticosteroids can be effective in significantly improving the symptoms of acute CRPS,
“suggesting the possibility that inflammatory mechanisms might contribute to CRPS, at least in
the acute phase.” Id. at 5. Such an inflammatory mechanism could occur in either of two ways, by
means of classic inflammatory response through the actions of immune cells after tissue trauma or
by neurogenic inflammation. Both mechanisms would result in an increase in proinflammatory
cytokines secreted. Notably, the local blister fluid, circulating plasma, and cerebrospinal fluid
(“CSF”) of CRPS patients in some studies exhibited significantly elevated levels of TNF-α,
interleukin-1β, -2, and -6.
        Petitioner’s medical records, however, indicated that Petitioner’s proinflammatory
cytokines, specifically TNF-α and IL-1β, were not significantly elevated at the levels observed in
CRPS patients. On October 16, 2014, Petitioner’s CSF was tested for cytokine expression. Ex.
23 at 22. Petitioner’s IL-1β was measured at 1.6 pg/mL, with a reference factor of less than 1.0
pg/mL. Id. Though slightly above the reference factor indicated, I do not find this increase to be
significant in light of the increased levels of IL-1β recorded in CRPS patients studied.69,70
Petitioner’s TNF-α was measured at 1.7 pg/mL, within the reference factor of 1.2 – 15.3 pg/mL.
Ex. 23 at 10. Thus, I do not view Petitioner’s TNF-α or IL-1β levels to be indicators of CRPS.

        Second, Petitioner’s theory depends on a heightened mast cell response triggered by an
allergic reaction to the vaccination. There was no indication in Petitioner’s medical records of any
irregularly heightened mast cell expression. Though an allergic reaction was noted by Dr.
Mardiney, Dr. Mardiney did not observe any signs of the reaction during the appointment and,
69
  Alexander GM, et al. Changes in Plasma Cytokines and Their Soluble Receptors in Complex Regional
Pain Syndrome. J Pain 2012; 13(1): 10-20 (filed as Ex. 78, hereinafter referred to as Ex. 78).
70
  In one such study, cluster analysis revealed that in a subgroup of patients, “the increase in … IL-1β [is]
related to the pathophysiology of the disease.” Ex. 78 at 8. In comparison to 2.16 pg/mL in control patients,
increases of plasma cytokines to 2.47 and 3.17 pg/mL in CRPS patients were not considered significantly
different from controls. Id. at 7.


                                                     56
therefore, did not find it severe enough to request further diagnostic testing. As such, no ongoing
mast cell expression was recorded. Even if Petitioner had suffered from an allergic reaction,
triggering a typical mast cell response, there is no clear indication in the medical records that this
response did not resolve or that it led to the development of nerve injury.

        Therefore, even if Petitioner’s theory of causation were viable under a more likely than not
standard, Petitioner’s diagnostic testing did not support the existence of the underlying factors
necessary for Petitioner’s purported causative process to occur. There is not preponderant evidence
that the flu vaccination did cause CRPS in Petitioner’s case.

        3. Althen Prong 3: One Month Post Vaccination Is a Medically-Appropriate Onset
           Interval

       As discussed extensively above, I do not find that Petitioner has CRPS. It is within this
framework that I analyze whether the onset of her CRPS occurred within a medically feasible time
frame.

         Accounting for Petitioner’s assertion of onset, Dr. Aradillas initially stated that Petitioner’s
first presentation of CRPS was likely her ear pain, one month following vaccination. However,
Petitioner’s ear pain had resolved by November 4, 2011, making this symptom inconsistent with
a CRPS diagnosis. See supra. Ex. 20 at 4. If Petitioner’s ear pain were a presentation of CRPS,
according to Dr. Low, the onset would have occurred within a medically feasible time frame. 71
However, CRPS is characterized by a presentation of regional pain. When questioned about
Petitioner’s region of pain at the onset of her CRPS, Dr. Aradillas testified that Petitioner’s region
of pain was her left and right buttocks, extending bilaterally to her thighs and knees. If this were
instead Petitioner’s initial presentation of pain, then onset is difficult to determine, since Petitioner
exhibited similar symptoms prior to vaccination. After vaccination, Petitioner did not seek
treatment for such pain until December 9, 2011, about two months after she received her flu shot.

       Assuming for the sake of this analysis that Petitioner had CRPS, and the onset of her
disease began with ear pain approximately one month after vaccination, I find that Petitioner
provided preponderant evidence in support of Althen prong 3.

VI. Conclusion

        Upon careful evaluation of all the evidence submitted in this matter, including the medical
records, tests, and reports, as well as the experts’ opinions and medical literature, I conclude that
Petitioner has not shown by preponderant evidence that she is entitled to compensation under the
Vaccine Act. Petitioner has failed to offer credible evidence showing that she suffered from CRPS,
and she has failed to show that the vaccination she received caused any of her complaints. Her
petition is therefore DISMISSED. The clerk shall enter judgment accordingly.72

71
  Dr. Low testified that the condition would “develop rapidly, certainly within two months, probably within
a month.” Tr. at 194.
72
  Pursuant to Vaccine Rule 11(a), the parties may expedite entry of judgment by each filing (either jointly
or separately) a notice renouncing their right to seek review.

                                                    57
IT IS SO ORDERED.


                         s/ Katherine E. Oler
                         Katherine E. Oler
                         Special Master




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