Spine Pain and Disability

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Spine Pain and Disability

• Timothy Cuddigan
• NOSSCR Fall 2008

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Listing 1.04 Disorders of Spine

• 1.04 Disorders of the spine (e.g., herniated
  nucleus pulposus, spinal arachnoiditis, spinal
  stenosis, osteoarthritis, degenerative disc
  disease, facet arthritis, vertebral fracture),
  resulting in compromise of a nerve root
  (including the cauda equina) or the spinal cord.
  With
• A. Evidence of nerve root compression
  characterized by neuro-anatomic distribution of
  pain, limitation of motion of the spine, motor
  loss (atrophy with associated muscle weakness or
  muscle weakness) accompanied by sensory or reflex
  loss and, if there is involvement of the lower
  back, positive straight-leg raising test (sitting
  and supine)
• OR

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Listing 1.04 Disorders of Spine

• B. Spinal arachnoiditis, confirmed by an
  operative note or pathology report of tissue
  biopsy, or by appropriate medically acceptable
  imaging, manifested by severe burning or painful
  dysesthesia, resulting in the need for changes in
  position or posture more than once every 2 hours
• OR
• C. Lumbar spinal stenosis resulting in
  pseudoclaudication, established by findings on
  appropriate medically acceptable imaging,
  manifested by chronic nonradicular pain and
  weakness, and resulting in inability to ambulate
  effectively, as defined in 1.00B2b.

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Spine Definitions used in listings

• Neuro anatomic distribution of pain
• Straight leg raising sitting and supine
• Range of Motion of Spine
• Muscle spasms
• Motor loss
• Inability to walk on heels or toes, to squat,
  arise from squatting position
• Muscle strength
• Condition of muscles (eg. Weakness, atrophy)

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Spine Definitions used in listings

• Deep Tendon Reflexes
• Sensory loss
• Description of gait
• Herniated Nucleus Pulposis
• Spinal arachnoiditis
• Spinal Stenosis
• Pseudoclaudication

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404.1529 How we evaluate symptoms, including pain

• (a) General. In determining whether you are
  disabled, we consider all your symptoms,
  including pain, and the extent to which your
  symptoms can reasonably accepted as consistent
  with objective medical evidence and other
  evidence.

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404.1529 How we evaluate symptoms, including pain

• (b) Need for medically determinable impairment
  that could reasonably be expected to produce your
  symptoms, such as pain.

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404.1529 How we evaluate symptoms, including pain

• (c) Evaluating the intensity and persistence of
  your symptoms, such as pain, and determining the
  extent to which your symptoms limit your capacity
  for work.

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404.1529 How we evaluate symptoms, including pain

• (1) General. When the medical signs or laboratory
  findings show that you have a medically
  determinable impairment that could reasonably be
  expected to produce your symptoms such as pain,
  we must then evaluate the intensity and
  persistence of your symptoms to determine how
  your symptoms limit your capacity for work.

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404.1529 How we evaluate symptoms, including pain

• (2) Consideration of objective medical evidence.
  Objective medical evidence is evidence obtained
  from the application of medically acceptable
  clinical and diagnostic techniques such as
  evidence of reduced joint motion, muscle spasm,
  sensory deficit or motor disruption.

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404.1529 How we evaluate symptoms, including pain

• (3) Consideration of other evidence. Since
  symptoms sometimes suggest a greater severity of
  impairment than can be shown by objective medical
  evidence alone, we will carefully consider any
  other information you may submit about your
  symptoms. (e.g. what may precipitate or aggravate
  your symptoms, what medications, treatments or
  methods you use to alleviate them, and how
  symptoms may affect you pattern of daily living.

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404.1529 How we evaluate symptoms, including pain

• (4) How we determine the extent to which
  symptoms, such as pain, affect your capacity to
  perform basic work activities. We will consider
  (c) (1) to (c) (3) above. We will consider your
  statements about the intensity, persistence and
  limiting effects of your symptoms and we will
  evaluate your statements in relation to the
  objective medical evidence and other evidence.

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404.1529 How we evaluate symptoms, including pain

• (d) Consideration of symptoms in the disability
  determination process. We follow a set order of
  steps to determine whether you are disabled.

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404.1529 How we evaluate symptoms, including pain

• (1) Need to establish a severe medically
  determinable impairment. Your symptoms, such as
  pain, fatigue, shortness of breath, weakness or
  nervousness are considered in making a
  determination as to whether your impairment is
  severe.

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404.1529 How we evaluate symptoms, including pain

• (2) Decision whether the Listing of impairments
  is met. Generally when a symptom is one of the
  criteria in a listing, it is only necessary that
  the symptom be present in combination with the
  other criteria.

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404.1529 How we evaluate symptoms, including pain

• (3) Decision whether the Listing of Impairments
  is medically equaled. We will not substitute
  your allegations of pain or other symptoms for a
  missing or deficient sign or laboratory finding
  to raise the severity of your impairment to that
  of a listed impairment.

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404.1529 How we evaluate symptoms, including pain

• (4) Impact of symptoms (including pain) on
  residual functional capacity. If you have a
  medically determinable severe physical or mental
  impairment, but your impairment does not meet or
  equal an impairment in appendix 1 of this
  subpart, we will consider the impact of your
  impairment and any related symptoms including
  pain, on your residual functional capacity.

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404.1528 Symptoms, signs and laboratory findings

• (a) Symptoms are your own description of your
  physical or mental impairment. Your statements
  alone are not enough to establish that there is a
  physical or mental impairment.

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404.1528 Symptoms, signs and laboratory findings

• (b) Signs are anatomical, physiological, or
  psychological abnormalities which can be
  observed, apart from your statements (symptoms).
  Signs must be shown by medically acceptable
  clinical diagnostic techniques. Psychiatric signs
  are medically demonstrable phenomena that
  indicate specific psychological abnormalities,
  e.g., abnormalities of behavior, mood, thought,
  memory, orientation, development, or perception.
  They must also be shown by observable facts that
  can be medically described and evaluated.

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404.1528 Symptoms, signs and laboratory findings

• (c) Laboratory findings are anatomical,
  physiological, or psychological phenomena which
  can be shown by the use of medically acceptable
  laboratory diagnostic techniques. Some of these
  diagnostic techniques include chemical tests,
  electrophysiological studies (electrocardiogram,
  electroencephalogram, etc.), roentgenological
  studies (X-rays), and psychological tests.

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SSR 96-3p Considering Allegations of Pain and
Other Symptoms in Determining Whether a Medically
Determinable Impairment is Severe

• 1. The evaluation of whether an impairment(s) is
  "severe" that is done at step 2 of the applicable
  sequential evaluation process set out in 20 CFR
  404.1520, 416.920, or 416.924 requires an
  assessment of the functionally limiting effects
  of an impairment(s) on an individual's ability to
  do basic work activities or, for an individual
  under age 18 claiming disability benefits under
  title XVI, to do age-appropriate activities and
  

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SSR 96-3p CONSIDERING ALLEGATIONS OF PAIN AND
OTHER SYMPTOMS IN DETERMINING WHETHER A MEDICALLY
DETERMINABLE IMPAIRMENT IS SEVERE

• 2. An individual's symptoms may cause limitations
  and restrictions in functioning which, when
  considered at step 2, may require a finding that
  there is a "severe" impairment(s) and a decision
  to proceed to the next step of sequential
  evaluation

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 1. No symptom or combination of symptoms can be
  the basis for a finding of disability, no matter
  how genuine the individual's complaints may
  appear to be, unless there are medical signs and
  laboratory findings demonstrating the existence
  of a medically determinable physical or mental
  impairment(s) that could reasonably be expected
  to produce the symptoms

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 2. When the existence of a medically determinable
  physical or mental impairment(s) that could
  reasonably be expected to produce the symptoms
  has been established, the intensity, persistence,
  and functionally limiting effects of the symptoms
  must be evaluated to determine the extent to
  which the symptoms affect the individual's
  ability to do basic work activities. This
  requires the adjudicator to make a finding about
  the credibility of the individual's statements
  about the symptom(s) and its functional effects.

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 3. Because symptoms, such as pain, sometimes
  suggest a greater severity of impairment than can
  be shown by objective medical evidence alone, the
  adjudicator must carefully consider the
  individual's statements about symptoms with the
  rest of the relevant evidence in the case record
  in reaching a conclusion about the credibility of
  the individual's statements if a disability
  determination or decision that is fully favorable
  to the individual cannot be made solely on the
  basis of objective medical evidence

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 4. In determining the credibility of the
  individual's statements, the adjudicator must
  consider the entire case record, including the
  objective medical evidence, the individual's own
  statements about symptoms, statements and other
  information provided by treating or examining
  physicians or psychologists and other persons
  about the symptoms and how they affect the
  individual, and any other relevant evidence in
  the case record. An individual's statements about
  the intensity and persistence of pain or other
  symptoms or about the effect the symptoms have on
  his or her ability to work may not be disregarded
  solely because they are not substantiated by
  objective medical evidence.

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 5. It is not sufficient for the adjudicator to
  make a single, conclusory statement that "the
  individual's allegations have been considered" or
  that "the allegations are (or are not) credible."
  It is also not enough for the adjudicator simply
  to recite the factors that are described in the
  regulations for evaluating symptoms. The
  determination or decision must contain specific
  reasons for the finding on credibility, supported
  by the evidence in the case record, and must be
  sufficiently specific to make clear to the
  individual and to any subsequent reviewers the
  weight the adjudicator gave to the individual's
  statements and the reasons for that weight.

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 1. The individuals daily activities
• 2. The location, duration, frequency and
  intensity of the individuals pain or other
  symptoms
• 3. Factors that precipitate and aggravate the
  symptoms
• 4 The type, dosage, effectiveness and side
  effects of any medication the individual takes or
  has taken to alleviate pain or other symptoms

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SSR 96-7p EVALUATION OF SYMPTOMS IN DISABILITY
CLAIMS ASSESSING THE CREDIBILITY OF AN
INDIVIDUAL'S STATEMENTS

• 5. Treatment, other than medication, the
  individual receives or has received for relief of
  pain or other symptoms
• 6. Any measures other than treatment the
  individual uses or has used to relieve pain or
  other symptoms( e.g. lying flat on his or her
  back, standing for 15-20 minutes every hour or
  sleeping on a board) and
• 7. Any other factors concerning the individuals
  functional and restrictions due to pain or other
  symptoms.

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Practical Tips

• Request a medical source statement or report
• Request opinion about consistency of symptoms
• Examine client about pain and other symptoms
• Plan and try your clients case