Residual Functional Capacity Assessment for Back Pain
What Is RFC?
If your back injury is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimantâ€™s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Individuals with spine abnormalities involving the cervical spine (neck) are not as limited as those involving the lumbar spine (lower back). The ability to perform overhead work is often limited and can be an important consideration. However, the overhead work restriction is not limited to cervical fusions. An fusion of the cervical spine caused by arthritis would have the same effect, as would any condition of the cervical spine that results in painful movement and stiffness, like the inflammatory spondyloarthropathies (e.g., ankylosing spondylitis), or simply advanced osteoarthritis.
The Social Security Administration is liable to overlook rotational movement ability in the neck as an important work-related limitation. Even less regard is given to rotational ability in the lower spine. While these functions are not as important as bending and the ability to look upward, they could be a critical in some claimsâ€”especially the ability to look right and left without having to turn the whole body.
Grade I spondylolisthesis is rarely symptomatic and often found incidentally on X-ray. Grade I patients generally do not receive any restrictions from orthopedic surgeons. As a generalization, symptomatic grade II spondylolisthesis can result in restriction to medium work; grade III restriction to light work; and grade IV can sometimes be limited to sedentary work. However, this degree of functional severity is unusual and refers only to those rare cases with significant symptoms.
Spondylolisthesis is an anatomical abnormality that does not, by its mere appearance on imaging studies, imply symptoms or functional limitation. For example, some studies over a period of years showed no symptoms in over a third of patients followed with grades III and IV spondylolisthesis, and only mild symptoms in over half of the cases with grade IV slippage.
Of course, all cases must be evaluated in light of the individual claimantâ€™s symptoms. Persistent, significant back pain related to spondylolisthesis and not responding to conservative treatment is likely to be treated with lumbar fusion.
In uncomplicated cases of an HNP (herniated disc) and treatment with a surgical discectomy (see Figure 11 below) and laminectomy, the Social Security Administration will generally tend toward giving a medium RFC with occasional bending. If there are additional problems, such as associated arthritis elsewhere in the spine, surgery at multiple levels, or persistent pain, then the RFC should be lower. The important point is that the Social Security Administration should give no higher than a medium RFC (lifting up to 50 lbs) if modest pain persists. The most appropriate RFC for an individual claimant may be lower. A completely asymptomatic claimant after a simple laminectomy might receive no restriction in regard to back impairment.
Generally speaking, the Social Security Administration considers a 3 to 4 month recovery period sufficient for cases involving post-operative laminectomy or spinal fusion. This is true only in the absence of complications.
Figure 11: Detail of a lumbar discectomy.
Cervical or Lumbar Fusion
In cases of trauma, or the need of stabilization to alleviate chronic pain, the spine may be surgically fused (see Figure 12 below). In these cases, the Social Security Administration is likely to give no higher than a medium RFC with occasional bending even in cases of optimum post-surgical recovery. Those with any significant chronic pain generally receive no higher than a light RFC with occasional bending.
Figure 12: Vertebral fusion involving placement of a bone graft into a hollowed out disc space.
Fusions of the cervical spine are less limiting in regard to lifting and carrying, since they are not in the weight-bearing part of the spine. However, lifting heavy weights can put traction on the cervical spine through the back and neck muscles, resulting in symptoms. In other words, the lack of pain or other symptoms during resting physical examination does not imply the absence of limitation at heavier work-loads.
Some claimants who have had a fractured and unstable cervical spine during an accident, may warrant no higher than a sedentary RFC, if there is risk of death or spinal cord injury from heavier work. Also, there may be a residual neurological deficit from spinal cord injury at the time of injury, in the case of the accident.
In other instances, a decompressive cervical laminectomy and fusion is necessary to relieve spinal stenosis pressure on the cervical spinal cord. These cases are likely to require more limitation than those with a simple, uncomplicated cervical fusion. If the claimant has had pain lifting during his or her activities of daily living or attempt to return to a prior job, it is important that this information be documented in his or her disability file. Furthermore, cervical fusions can make it impossible for a person to perform overhead work, which can be a critical limitation in some cases.
Location of Arthritis
Generally speaking, arthritis occurring in the thoracic spine is not as symptomatic or functionally limiting as arthritis in the lumbar or cervical spine. Similarly, cervical spine arthritis is not as limiting as that in the lumbar spine of the same severity. Of course, individual cases may differ.
Claimants who do not meet the listing still may have limitations imposed by osteoporosis. Many post-menopausal women have osteoporosis of the spine but do not have the generalized osteoporosis required by the part B of the listing.
In the absence of generalized osteoporosis and the presence of a 50% compression fracture and symptoms of back pain, the Social Security Administration will generally agree that a RFC is no higher than medium work and could be lowerâ€”especially if there are multiple fractures.
Some spinal osteoporosis can be so severe that, when viewed with even plain X-rays, the vertebral bodies have an obviously thinned out ghost-like appearance. These claimants may be restricted to as low as sedentary work, based on the obvious conclusion that to lift more than minor weight would likely cause spinal fractures. Sometimes, it is important for Social Security Administration doctors to obtain X-rays from the source and look at the images themselves. If there is any question about the severity of the osteoporosis, the Social Security Administration should obtain bone densitometry for a more accurate measurement.
In cases of spinal stenosis that are not severe enough to satisfy the listing, the Social Security Administration should nevertheless take care that the RFC given does not result in symptoms. The important questions are:
- How much weight can you lift and carry, both frequently and occasionally, without symptoms?
- How long can you walk or stand?
If standing or walking is limited to less than 6 to 8 hours daily, then you are automatically restricted to sedentary work. It is important to ascertain the difference between standing and walking while carrying nothing and while carrying something. For example, a claimant with symptomatic lumbar stenosis may be able to stand or walk 6 to 8 hours, but not necessarily while carrying 20 lbs. In that instance, the RFC would be restricted to sedentary work. Careful case development of the claimantâ€™s symptoms is necessary to determine RFCs in these cases.
It is difficult to assess how far a person can walk or how much a person can lift just by looking at imaging studies showing the anatomical severity of spinal stenosis. Greater weight should be given to alleged symptoms and limitations in activities of daily living than trying to guess RFC from imaging results. The only exceptions might be in highly atypical cases where, for example, a claimant with extremely mild spinal stenosisâ€”perhaps borderline abnormalâ€”alleges marked limitations.
Artificial Intervertebral Disks
Artificial spinal disk implants are not yet common enough to know how well they will permit repeated flexion of the spine on a day-to-day basis. It is also unknown what weights patients will reasonably be able to lift frequently or occasionally, or lift and carry. Larger studies with many more patients will be required to answer those questions. At the present time, it would seem reasonable to restrict lumbar, single artificial disk patients to no more than light workâ€”provided there is no functional information to the contraryâ€”with occasional bending. It is less clear what RFC is reasonable in a person with a single, cervical artificial disk since that part of the spine is not as weight bearing. These cases should never be assessed as â€śnot severeâ€ť (slight). Furthermore, multiple artificial disksâ€”regardless of their locationâ€”would warrant no higher than a light RFC. Of course, significant symptoms could decrease these capacities.
Vertebroplasty involves stabilizing fractured vertebrae with glue (polymethylmethacrylate, PMMA), also referred to as â€śbone cement.â€ť It was first used in 1984 to treat compression fractures caused by cancer, and since 1994 has been used to treat osteoporotic compression fractures. Vetebroplasty is a common procedure. The glue is injected under local anesthesia, with resulting improvement in spinal mobility and back pain in about 96% of patients. The pain relief is often very substantial with a corresponding increase in function and the quality of life. It would seem reasonable that osteoporosis requiring vertebroplasty for compression fractures would limit the RFC to no higher than light work to avoid additional fractures.
Chronic Back Pain after Multiple Surgeries
Some claimants have severe spinal arthritis, multiple surgeries, and persistent chronic pain both sitting and standing. Multiple back surgeries are particularly notorious for causing chronic back pain problems and these claimants may show scarring around nerve roots on CT or MRI. Such scarring may be the only rational basis for alleged persistent pain. Cases of severe persistent back pain are unusual but not rare, and require careful medical judgment to determine if the claimantâ€™s residual functional capacity precludes even sedentary work. The claimant may be restricted to sedentary work, and have to frequently alternate sitting and standing. In that event, the claim is almost always allowed since it is difficult to find jobs that a person with that kind of limitation can do. Critical in this determination is not only the objective medical evidence, but consideration of the treating doctorâ€™s opinion and the claimantâ€™s activities of daily living (ADLs). The credibility of the claimantâ€™s pain-related allegations increases substantially when there is a well-documented interaction with the treating doctor in which the claimant describes and attempts to get relief for pain. Particularly important is the treating doctorâ€™s opinion about how long he or she thinks the claimant can sit or stand in any one period of time as well as on a total daily basis.
If a claimant is otherwise limited to sedentary work and also unable to sit at least two hours in one period without standing, it would be difficult for the Social Security Administration to cite a job the claimant can perform. It is important for the treating doctor to rationalize to the Social Security Administration why severe functional limitations are present, for example, to refer to the medical evidence showing objective abnormalities and provide the findings of a careful physical examination.