Winning Social Security Disability Benefits for Stroke by Meeting a Listing
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your stroke is severe enough to meet or equal the stroke listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that Social Security Administration presumes would prevent a person from performing substantial work. If your stroke is severe enough to meet or equal the stroke listing, you will be considered disabled.
If you believe you are disabled because of a stroke, the Social Security Administration will not evaluate your case until at least 3 months have passed since the stroke occurred. It takes at least this long to find out how much you will recover. Exceptions could be claimants with such extreme brain damage proven by physical examination, or brain scans that they are comatose and not likely to survive or show any significant recovery in 3 months. It would be pointless to actually hold such cases for 3 months. However, in most cases prediction of the degree of recovery from a CVA is unreliable.
If your stroke caused or worsened a mental impairment, your mental impairment will evaluated under the mental impairment listings. The most likely emotional problems post-CVA are depression and organic brain syndrome. Mental impairments post-CVA is an area that the Social Security Administration is particularly likely to overlook.
The listing for stroke is 11.04, which has two parts: A and B. Most post-CVA claimants who meet the listing do so under part B, rather than part A.
Meeting Social Security Administration Listing 11.04A for Stroke
You will be disabled under Listing 11.04A if you have had a stroke (central nervous system vascular accident) with sensory or motor aphasia resulting in ineffective speech or communication more than 3 months after your stroke.
What Is Aphasia?
Aphasia means difficulty in comprehension or expression of language.
Types of Aphasia
There are many types of aphasia.
- In sensory aphasia, a person may be unable to understand written or spoken words.
- In motor (expressive) aphasia, the person knows what he wishes to say, but is unable to form and speak the necessary words, or only with extreme difficulty and slowness. Or the motor aphasia might involve inability to put thoughts into writing.
- In global aphasia, receptive and expressive language ability is essentially non-existent. In other words, the person can neither understand words, nor speak.
- Broca’s (non-fluent) aphasia is characterized by a difficulty in the production of speech, which is accomplished by only several words at a time in a halting manner; writing is also impaired, but the person may be able to understand speech and to read.
- In mixed, non-fluent aphasia, the person has difficulty with speech, understanding, writing, and reading.
- In anomic aphasia, the person has difficulty finding the right nouns or verbs to use in speaking or writing.
- In Wernicke’s aphasia, a type of fluent aphasia, the person has little difficulty in producing speech in a mechanical sense, but does not understand the meaning of words, which results in inappropriate speech, and the claimant’s ability to read and write is also severely impaired.
How Severe Must Aphasia Be to Meet Part A
All degrees of sensory and motor aphasia are possible, but to fulfill part A, the aphasia must be so severe that communication with other people is ineffective. This means that useful verbal communication is not possible because there is severe impairment in the clarity, content, or sustainability of speech. Since 90% of people have their language processing abilities in the left side of the brain, a left brain stroke is more likely to produce problems with aphasia. Although many people with CVAs have some degree of aphasia, few have it so severely that they qualify under part A.
If the aphasia is so severe that the claimant is incapable of any communication, part A is obviously satisfied. But aphasia is usually only partial. In these instances, careful examination by a neurologist or psychiatrist can provide useful clinical information regarding severity. A formal evaluation of speech communication ability can be obtained from speech therapists.
Meeting Social Security Administration Listing 11.04B for Stroke
You will be disabled under this listing if you have had a stroke (central nervous system vascular accident) and more than 3 months afterwards you have significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station. Although nearly all CVAs seen by the Social Security Administration involve the brain, it is possible for there to be a CVA involving an artery supplying the spinal cord, which is also a part of the central nervous system. This event is most likely with spinal cord trauma or tumors. Since there is no brain involvement, spinal cord strokes are evaluated under part B.
Two Extremities Must Be Impaired
Part B identifies the two major areas of motor limitations as:
- Upper extremity (arm and hand) function including:
- Gross movements.
- Dexterous movements.
- Lower extremity (leg) function including:
- Gait – the manner of walking.
- Station – the manner of standing, i.e., ability to maintain a posture.
Two extremities must be involved to satisfy part B: both legs, both arms, or one arm and one leg.
Almost all stroke cases affect an upper and lower extremity on the same side of the body. When one side of the brain is damaged, any abnormalities like paralysis are going to be on the opposite side of the brain affected by the stroke. This is because the left side of the brain controls the right side of the body and vice versa. A stroke in the left hemisphere of the brain will produce deficits in the right side of the body and vice versa. A stroke on the side of the brain opposite from the dominant hand will result in greater loss of function than a stroke affecting the non-dominant hand. For example, if you are right handed, a stroke on the left side of the brain affecting use of your right hand will be more disabling than a stroke on the right side of the brain affecting your left hand.
If a lower extremity alone (i.e., a single leg) is affected, the listing cannot be met. However, if the lower extremity is so weak that a hand-held assistive device such as a quad cane is necessary for walking, then use of an arm would be tied up, with the same functional result as paralysis of the arm. Such cases would equal the listing.
If you cannot stand and walk 6 to 8 hours daily and have any significant weakness or inability to manipulate objects with an upper extremity, part B is satisfied. Inability to stand or walk for such prolonged times does not necessarily depend only on lower extremity strength. An uncoordinated gait, or poor balance that results in an unreasonably slow pace is still not a functional gait from a work perspective and would meet the listing. This is particularly important if you have neurological dysfunction in both lower extremities, but not in the arms.
At a physical examination, a doctor can obtain information regarding strength in the upper and lower extremities with some simple and routine maneuvers. First, the examining physician can estimate strength loss by comparing the strength of muscle contraction on your weak side to your normal side. Physicians frequently report subjective determination of strength by using a scale of 0 to 5 with 5 being normal. For example a doctor might ask you to try to straighten out your leg while the doctor resists the movement. A weaker leg might be reported as 3/5 for the quadriceps muscle (muscle on the front of the thigh) compared to an expected normal of 5/5. Zero means no movement. One means a trace of movement. Two means movement with the help of gravity. Three means movement is possible against gravity, but not against resistance. Four means movement against gravity and resistance by the examining physician. Five means normal. Errors in this type of subjective testing can be caused by the person’s motivation, variations among people in “normal” strength, and differences in the doctor’s subjective assessment.
More objectively, a doctor can test your ability to walk on your heels and toes and squat and arise. Ability to walk on the toes means you can lift your body weight by contraction of your gastrocnemius (calf) muscles and implies significant strength. Ability to walk on the heels indicates that the muscles in the anterior (front) leg (opposite the calf muscles) that flex the foot still have good strength. Ability to squat and arise implies good strength of the quadriceps muscles of the thighs.
Determination of lower extremity strength after a stroke is very important, because if a person cannot stand 6 to 8 hours a day and an upper extremity is significantly affected then the listing will be fulfilled. If you cannot stand or walk 6 to 8 hours a day, you can do only sedentary work, but if you also have limited use of an upper extremity, you cannot even do sedentary work. If you cannot walk on heels or toes in the affected lower extremity after a CVA, it is not reasonable to expect that you would have the strength to stand 6 to 8 hours daily. If you can do such testing well, it is not likely you will qualify under listing 11.04B on the basis of strength deficit. However, you still may qualify based on severe lack of balance or coordination in walking.
Evaluating Walking and Balance
In evaluating how well you stand and walk, the Social Security Administration requires a detailed description from a medical doctor. This involves factors such as how weak your legs are, how much difficulty you have in keeping your balance, how fast you walk, how much help you need walking, and so forth. To meet the listing, you do not have to use a cane, crutch, brace, walker, or other assistive device to move about. Of course, if you need such devices, that would indicate a very severe limitation. However, the use of an assistive device such as a cane or crutch, or even a wheelchair, does not establish a severe limitation without supporting objective medical data. This is true, even if your treating doctor says you need the device.
After a severe CVA, walking (gait) and standing (station) may be affected in characteristic ways. If a leg and arm are weak from a CVA, a person will often walk with a circumducting gait. The weak leg moves forward with a circular motion and the weak arms has a short swing. On the other hand, a CVA in the brainstem or cerebellum may produce an unsteady (ataxic) gait, frequently with legs wide-based in an effort to compensate for the loss of balance. Your balance can be tested in neurological examination not only by observing your normal attempts at walking, but also by testing your ability to walk heel to toe. If there is weakness of the pelvic musculature, a waddling gait may result. A foot drop tends to cause a steppage gait, lifting the foot high to clear the toes from the ground. Spasticity, produced by increased muscle tone, can produce a stiff limb with inflexible movements.
Evaluating Arm and Hand Use
The use of the arms and hands is evaluated by looking at gross and dexterous movements. Dexterous movements are those like writing, picking up small objects, or other types of fine movements. Gross movements involve larger motions with the arms and hands. Movements can be influenced by weakness, or loss of control over the way an arm or hand moves, such as tremors or poor coordination. The ability to oppose fingertips to the thumb successively can give some idea as to the intactness of fine manipulatory (dexterous) ability. However, if you can do finger-thumb opposition only slowly and clumsily, then you should not be considered capable of dexterous movements. Also, your activities of daily living (ADLs) can be helpful in assessing functional severity when they describe specific inabilities or abilities (e.g., turning doorknobs, dressing, climbing stairs, shaving, etc.).
Medical Documentation of Stroke and Its Effects
You cannot convince the Social Security Administration that you are disabled just because you appear to have weakness, poor coordination, or impaired gait because all of these findings are under your control. Thus, your medical history is very important. Claimants who have actually had a severe CVA have been hospitalized. By obtaining the records from that hospitalization, the Social Security Administration can obtain a much better picture of clinical severity. The initial physical examination can be reviewed, along with the degree of recovery at the time of hospital discharge. Almost certainly, a CT or MRI scan was done of the brain and sometimes cerebral angiography. These studies can be most helpful in determining the location and severity of brain damage, so that it can be correlated with the clinical findings at the time of adjudication. Some claimants allege abnormalities that were not present at the time of their CVA and do not correspond to the location or magnitude of the initial brain lesion, or they seem to manifest weakness much greater than that present in their past medical records. If the claimant underwent rehabilitation in the past, that information is useful.
Certain objective signs are present after a CVA. Deep tendon reflexes (DTRs) in the affected parts of limbs should be hyperactive, or faster than normal. For example, tapping the patellar tendon below the knee (knee-jerk reflex) would cause the quadriceps muscle to more rapidly contract and the leg to extend more quickly than normal.
Reflexes are graded from 0 to 4. Zero (0) means no reflex. One (1) means a distinctly hypoactive (slow) and abnormal reflex. Two (2) and three (3) mean a normal reflex. Four (4) means a distinctively hyperactive and abnormal reflex. Physicians usually report reflexes in a right/left mode. For example, a knee-jerk (KJ) reflex reported as 4+/2 indicates a very pathological KJ on the right. Reports of 2/2 or 3/3 for reflexes should be interpreted as normal. However, asymmetry in reflexes may be significant, e.g., 2/3+ might indicate an abnormal reflex on the left.
Additional basic reflexes important in neurological examination include the achilles reflex (AJ), biceps jerk (BJ), triceps jerk (TJ), and brachioradialis reflex. There are others that might be important in particular circumstances. Also, there may be a positive Babinski sign, which means the great toe in the affected lower extremity moves upward when the bottom lateral surface of the foot is stroked. Normally, the great toe moves downward with this test. Therefore, when an examining doctor says there is a positive Babinski, this is an indication of some type of upper motor neuron lesion. An upper motor neuron lesion may also produce sustained clonus, which is a rhythmic relaxation and contraction of a muscle caused by suddenly stretching a tendon. Clonus is most frequently tested for by a doctor quickly pushing the foot upward to stretch the achilles tendon. Sustained beating movements of the foot are an abnormal clonus indicative of upper motor neuron disease. In addition, muscle tone is increased in upper motor neuron lesions, and, if marked, results in spasticity..