Monster Media 1994 #2/Monster Media No. 2 (Monster Media)(1994).ISO/text/ppsmisc1.zip/PPS&SSA.TXT

Text File | 1994-03-30 | 13KB | 252 lines

                    PROGRAM OPERATIONS MANUAL SYSTEM
                          Part 04 - Disability
                    Chapter 245 - Medical Evaluation
       Subchapter 80 - Evaluation of Specific Issues/Neurological

                             No. of                               No. of
New Material                  Pages   Discard                     Pages

Table of Contents                     Table of Contents
  (DI 24580.001-24580.010)......1       (DI 24580.001-DI 24580.004)...1
DI 24580.010E.3.-DI 24580.010F..3     --------

               _________________________________________
                              ACTION NOTE

               DI 24501--Add DI 24580.000 and subchapter
               title to the chapter Table of Contents.
               _________________________________________

                               Background

This transmittal discusses the late effects of anterior poliomyelitis
(polio) which may occur many years after the acute illness.  It
introduces guides concerning the documentation and evaluation of the new
functional problems being experienced by some polio survivors.  These
new functional limitations are causing increased impairment for some
individuals in the performance of usual daily activities including work
activities.

                     Explanation of Manual Changes

24580.010  Evaluation of Late Effects of Poliomyelitis

Subsection A defines acute anterior poliomyelites which is now generally
considered to be conquered in most industrialized countries because of
vaccines developed in the mid-1950's.  Also defined are late effects of
polio which, for program purposes, encompass those new functional
problems which may occur in an individual with a prior history of acute
poliomyelitis who has had a long period (generally 20-40 years) of
stability.

Subsection B describes the signs and symptoms of late effects of polio.
The include fatigue, loss of endurance, weakness and pain.

Documentation is discussed in subsection C.  This section provides
guidance on developing cases where late effects of polio are alleged.
The importance of a description of the initial illness (early records
are not required) and the types of current evidence needed are
discussed.

Meeting or equaling Listing 11.11 criteria, and determining residual
functional capacity are discussed in subsection D.  Subsections E-H
consider fatigue of specific muscle groups from repeated activity and
overall loss of endurance, weakness, common areas of pain problems and
the vocational implications of exposure to cold, which, for some
postpolio individuals, significantly impairs their ability to function.

Other program issues (onset, diagnosis coding, medical diaries and work
despite a severe impairment) are discussed in subsections I-L.

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

24580.010 Evaluation of Late Effects of Poliomyelitis

A.  Definition
  1.  GENERAL
  Anterior poliomyelitis (polio) is caused predominantly by three types
of polio viruses and occasionally by other viruses which may destroy
motor nerve cells in the spinal cord and medulla.  Permanent paralysis
may result.  The extent of permanent paralysis, if any, depends upon how
many nerve cells were destroyed.
  2.  LATE EFFECTS OF POLIO
  For the purposes of evaluation under the disability programs, the late
effects of polio refer to new symptoms and neuromuscular manifestations
which result in new functional loss in an individual with a prior
history of acute polio.  This functional loss typically occurs after a
long period (more than 10 years and generally 20-40 years) of stability.
  The etiology of these problems is not yet known and not all polio
survivors experience these late effects.  Precise data are not yet
available, but it may be that about 25 percent of the estimated 300,000
or more surviving individuals who had polio are experiencing new
problems affecting their ability to carry out accustomed activities.
These late neuromuscular effects are permanent and usually slowly
progressive.  There is no know treatment.

B.  Signs and Symptoms
  The late effects of polio (also referred to as postpolio syndrome or
sequalae) include fatigue, weakness, joint and muscle pain, breathing
difficulty, and intolerance of cold.  There may be increasing weakness
or pain in a muscle already paralyzed or in muscles not know to be
previously affected.  The severity of problems may range from a modest
worsening to a progressive postpolio muscular atrophy.
  The late effects of polio are causing increasing problems in
activities such as lifting, bending, prolonged standing, walking,
climbing stairs, pushing a wheelchair, transfers (e.G., from wheelchair
to toilet) sleeping, swallowing, dressing, and any activity requiring
repetition and endurance.
  Many polio survivors who thought they were in stable condition have
had to start using or add to previous use of bracing, canes, crutches,
wheelchairs or breathing aids.  Ability to continue with customary
activity, including work, has been curtailed for many of these
individuals.  Functional abilities which may have been limited, but
stable for many years, are now being lost.

C.  Documentation
  1.  GENERAL
  Careful development of the history to include a description of the
original diagnosis (old records are not required), degree of original
paralysis and residual paralysis, the types of new functional
restrictions encountered, onset of these problems, and accommodations
made in activities of daily living because of them are important.
  Detailed medical records from the treating source should be sought first.
In selected cases, where severity of the impairment is unclear, an
examination by a physiatrist (specialist in physical medicine and
rehabilitation) who is knowledgeable about polio, is appropriate, if one
is available.  (While most cases can be resolved without a physiatrist's
involvement, a physiatrist is, at present the best source for
information concerning the overall functional limitations in individuals
with postpolio problems.)  If a physiatrist is not available for
difficult cases, an evaluation by a neurologist, knowledgeable about
late effects of polio, should be sought.
  2.  SPECIAL STUDIES
  Electromyogram (EMG) and nerve conduction studies may be helpful in
defining the cause and extent of neuromuscular impairment.  If these
studies are available as evidence of record, they should be considered
along with all other evidence of record.  These studies should not be
purchased, except in rare, difficult cases where the examining
physiatrist or neurologist, in concurrence with the DDS physician, finds
these tests essential to establishing current functional status.

D.  Evaluation
  1.  MEETING OR EQUALING THE LISTING
  The listing criteria for polio (11.11) may be applied both to cases of
static polio (where there has been no reported worsening after initial
recovery), and cases where late effects of polio are manifested.
Evaluation of the overall impairment severity is the primary
consideration.  It is possible to meet or equal Listing 11.11 on the
basis of the late effects of polio even though medical science has not
yet fully defined the etiology of these late effects.
  2.  RESIDUAL FUNCTIONAL CAPACITY (RFC)
  In determining RFC when Listing 11.11 is neither met nor equaled, the
guides in DI 24510.000ff. should be followed.  Careful consideration
should be given to all factors, particularly those factors critical to
determining functional status in postpolio cases (see E-H below).

E.  Fatigue and Loss of Endurance
  1.  GENERAL
  Fatigue or loss of endurance may be experienced as a tiredness after
using a specific muscle or group of muscles (e.g., the individual can
produce one or two forceful contractions in manual muscle testing, but
cannot produce 5 or 10 contractions), or may be reported as an overall
unaccustomed tiredness.  Fatigue should always be evaluated within the
context of demonstrable abnormal organic residual neurological deficits
present.
  2.  TESTING FOR FATIGUE
  In selected cases, where fatigue is a critical factor to adjudication,
a simple repetitive activity test, performed by a physiatrist or
neurologist knowledgeable about late effects of polio, may be needed to
demonstrate the fatigue.
  3.  FATIGUE IN POLIO VERSUS OTHER NEUROLOGICAL DISORDERS
  The reason for the fatigue and loss of endurance in polio survivors is
not yet entirely clear but may be due to the fact that postpolio
individuals are using their muscles at intensities much above normal and
there is insufficient time for the muscle fibers to relax and chemically
restore themselves.
  The fatigue for a polio survivor is not identical to the fatigue
experienced by other neurologically impaired individuals. It is not,
therefore, appropriate to cite the listing criteria for multiple
sclerosis (11.09C) or for myasthenia gravis (11.12) when adjudication
polio cases.

F.  Weakness
  In evaluating weakness, special attention should be paid to
allegations of spinal problems related to lower extremity weakness,
with secondary degeneration of the lumbosacral joints on the side of the
paralysis.  These leg/spinal problems are commonly seen in postpolio
survivors and in combination can be severe enough to equal the intent of
11.11C  Weakness in the neck and shoulder muscles is also common.  This
may interfere with proper support of the head or use of the arms.

G.  Pain
  Pain symptoms should be evaluated under DI 24515.060 (Evaluation of
Pain and Other Symptoms).  They types of pain syndromes often occurring
in individuals with post polio problems include bursitis and tendonitis
around the shoulders, myofacial pain in the neck and should and low
back, postural pain problems throughout the spine that are frequently
associated with scoliosis and leg length discrepancies and joint pain in
the lower extremities, especially the knee.

H.  Cold Intolerance
  Changes in environmental temperature can at times significantly alter
muscle strength and dexterity and produce pain in postpolio individuals.
The intolerance of cold may prevent a postpolio individual from engaging
in jobs where exposure to cold is unavoidable.

I.  Onset
  Onset in cases involving late effects of polio should be set based on
allegations, work history and other evidence concerning impairment
severity in accordance with DI 25501.001ff.  Generally, the new problems
are gradual and nontraumatic, but acute injuries or events (e.g.,
herniated discs, broken bones from falls) may be the markers of onset of
disability.

J.  Diagnosis Coding
  If late effects of acute polio is the primary diagnosis, use code 1380
to record the diagnosis.

K.  Medical Diaries
  Where the primary diagnosis is polio, a medical improvement not
expected diary, code 036, is appropriate per DI 26525.040C, impairment
number 21.

L.  Work Despite a Severe Impairment
  Many individuals with severe polio residuals have accommodated to their
limitations and have worked despite them.  They are now experiencing
new functional problems which they allege are preventing their
continuing to pursue their present work.  In evaluating such cases under
DI 24005.005, careful consideration should be given to evidence of
worsening of the impairment.  A new, minor weakening in muscles critical
to certain activities (e.G., walking, standing, using arms or hands) may
effectively alter ability to continue to function at the same level as
was maintained for may years after the initial recovery from polio.

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
This is pages 59 and 60, dealing with polio, from SSA's booklet
DISABILITY EVALUATION UNDER SOCIAL SECURITY.  Show this to your doctors
before they write their letters so that they can see how these
impairments are categorized by SSA and so that they will couch their
responses to SSA's questions in SSA's terms:

                    11.01  CATEGORY OF IMPAIRMENTS,
                           NEUROLOGICAL

11.04  Central nervous system vascular accident.  With one of the
following more than 3 months post-vascular accident:

A.  Sensory or motor aphasia resulting in ineffective speech or
communication; or

B.  Significant and persistent disorganization of motor function in two
extremities, resulting in sustained disturbance of gross and dexterous
movements, or gait and station. (see 11.00C).

11.11  Anterior poliomyelitis.  With:

A.  Persistent difficulty with swallowing or breathing; or

B.  Unintelligible speech; or

C.  Disorganization of motor function as described in 11.04B.