Assessing Neurological Disability

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Assessing Neurological Disability

• Corina Azores-Macalintal, M.D., F.P.N.A

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Questions

• When is the patient neurologically disabled?
• What kind of neurological disabilities does
  neurological diseases brings?

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Disability

• Definition
• Inability to engage in any substantial gainful
  activity by reason of any medically determined
  physical or mental impairment(s) which can be
  expected to result to death or which has lasted
  or can be expected to last for a continuous
  period of time.

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When is the patient neurologically disabled?

• Mental/ cognitive
• Visual / auditory
• Motor
• Sensory
• Balance and Coordination
• Gait

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Mental Disability

• Language dysfunction (Aphasia)
• Executive dysfunction
• Memory dysfunction

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Aphasia

• Acquired impairment of comprehension and
  production of verbal language caused by brain
  damage.
• Alexia and agraphia often co-exist with aphasia

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Aphasia

• Four areas of language functioning
• Auditory comprehension
• Repetition
• Fluency of verbal expression
• Confrontation naming

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Aphasia

• Non-fluent
• Brocas
• Transcortical motor
• Global
• Mixed Transcortical
• Fluent
• Wernickes
• Transcortical sensory
• Conduction
• Anomic

• Auditory comprehension
• Asyntactic
• Can be asyntactic
• Severe impairment and
• Retain prosody
• Like global
• Milder than global
• Asyntactic
• intact

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Aphasia

• Non-fluent
• Brocas
• Transcortical motor
• Global
• Mixed Transcortical
• Fluent
• Wernickes
• Transcortical sensory
• Conduction
• Anomic

• Verbal expression
• Agrammatism, aprosodia, apraxia of speech, poor
  repetition
• Poor initiation, elaboration, intact
  repetition,echolalia
• Limited to automatisms, stereotypies, poor
  repetition
• Limited spontaneous, intact repetition, echolalia
• Nonmeaningful logorrhea, anosognosia
• Intact repetition, echolalia
• Conduit dapproche, poor repetition
• Pauses for word retrieval, intact repetition

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Aphasia

• Non-fluent
• Brocas
• Transcortical motor
• Global
• Mixed Transcortical
• Fluent
• Wernickes
• Transcortical sensory
• Conduction
• Anomic

• Typical word retrieval errors
• Semantic, verbs worse than nouns
• No response, perseverations
• Stereotypies, semantic
• Stereotypies, semantic
• Neogolisms, semantic, phonemics
• Semantic, phonemic, circumlocutions
• Phonemics, semantic
• Circumlocutions, no response, semantic, nouns
  worse than verbs

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Aphasia

• Non-fluent
• Brocas
• Transcortical motor
• Global
• Mixed Transcortical
• Fluent
• Wernickes
• Transcortical sensory
• Conduction
• Anomic

• Left Hemisphere lesion locations
• Inf. Frontal, operculum
• Dosolateral frontal, or thalamus
• Large pre-rolandic post rolandic
• Watershed/ extrasylvian cortex
• Superior temporal
• Temoral-parietal or degenerative
• Parietal, insula
• Inferior temporal or thalamus or degenerative

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Executive Dysfunction

• Impairments in initiation, intention, planning,
  sequencing, inhibition, flexibility, monitoring
  and various complex aspects of attention

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Memory Dysfunction

• MCI
• Dementia

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Dementia

• Memory impairment (learning and recall)
• One or more
• Aphasia
• Apraxia
• Agnosia
• Dysexecutive function (planning, organizing,
  sequencing, abstracting)
• deficits of sufficient severity to affect
  social or occupational functioning

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Limb Apraxia

• Impaired ability to perform skilled, purposeful
  limb movements as a result of neurologic
  dysfunction
• excluding weakness, akinesia, abnormalities
  of tone or posture and movement disorders

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Limb Apraxia

• Type
• Limb-kinetic
• Ideomotor
• Ideational
• conceptual

• Clinical features
• Impaired ability to make finem precise,
  independent finger movements
• Gesture production errors
• Impaired sequencing of tool use
• Content errors in tool use, errors in tool
  selection

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Limb Apraxia

• Type
• Limb-kinetic
• Ideomotor
• Ideational
• conceptual

• Assessment tasks
• Rotate coin between thumb and fingers
• Gesture to command, gesture imitation
• Serial acts (e.g. fold letter place in envelope,
  seal, stamp)
• Tool-object matching (hammer and nail)

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Assessment Tools
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Mini Mental State Examination(MMSE)

• Orientation
• Registration
• Attention and Calculation
• Recall
• Language

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Neuropsychological Testing

• Comprehensive examinations may be used to
  establish the existence and extent of compromise
  of brain function

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Neuropsychological Testing

• Cerebral dominance
• basic sensation and perception
• motor speed and coordination,
• attention and concentration,
• visual-motor function
• memory across verbal and visual modalities

• Receptive and expressive speech
• Higher-order linguistic operations
• Problem-solving
• Abstraction ability
• General intelligence

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Neuropsychological Testing

• Should include evaluating pathological features
  as
• Emotional lability
• Abnormality of mood
• Impaired impulse control
• Passivity and apathy
• Inappropriate social behavior

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Criteria for Organic Mental Disorder
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A. Loss of specific cognitive abilities and
medically documented persistence of at least one
of the FF

• Disorientation to time and place, or
• Memory impairment (short-term, intermediate, or
  long-term), or
• Perceptual or thinking disturbances (e.g.
  hallucinations, delusions, or
• Change in personality, or
• Disturbance in mood, or
• Emotional lability (e.g. explosive temper
  outbursts, sudden crying) and impairment of
  impulse control
• Loss of measured intellectual ability of at least
  15 I.Q points from premorbid levels or severely
  impaired range on neuropsychological testing

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And B. Resulting in at least two of the
following

• Marked restriction of activities of daily living
  or
• Marked difficulties in maintaining social
  functioning or
• Marked difficulties in maintaining concentration,
  persistence, or pace or
• Repeated episodes of decompensation, each of
  extended duration

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Or C. Medically documented history of chronic
organic mental disorder of at least 2 years and
one of the following

• Repeated episodes of decompensation, each of
  extended duration
• A residual disease process that has resulted in
  such marginal adjustment that even a minimal
  increase in mental demands or change in the
  environment would be predicted to cause the
  individual to decompensate

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• Current history of 1 or more years inability to
  function outside a highly supportive living
  arrangement, with an indication of continued need
  for such an arrangement

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Visual

• Presentations
• Visual loss/blurring
• Visual field defects (anopsia)

• Assessment
• Field testing
• Fundoscopy
• Visual acuity test (Snellen)
• VEP

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auditory

• Presentation
• Deafness
• Tinnitus
• Dizziness

• Assessment
• Weber, Rinnes
• Audiogram
• BAER

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• Motor, sensory, balance, coordination and gait
  disabilities
• disorganization of motor function

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Disorganization of Motor function

• In the form of paresis or paralysis, tremor or
  other involuntary movements, ataxia, sensory
  disturbances which may occur singly or in various
  combinations

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Disorganization of Motor function

• Assessment of impairment depends on the degree of
  interference with locomotion and/or interference
  with the use of fingers, hands and arms.

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Assessment

• Motor Strength
• Sensory
• Light touch, pressure, heat / cold,
  proprioception
• abnormal sensation as dysaesthesia,
  allodynia, hyperaesthesia

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Assessment

• Balance, coordination and gait
• Finger to nose test / heal to shin test
• Tandem walking

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Category of Neurological Impairments
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Convulsive Seizure

• Degree of impairment
• Determined according to type, frequency, duration
  and sequelae
• At least 1 detailed description of a typical
  seizure
• Presence of associated signs/ symptoms
• Documentation with at least 1 EEG

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Convulsive seizure

• Only if impairment persists despite treatment
• Blood levels of anticonvulsant medications
• Compliance to anticonvulsant medication
• Idiosyncrasy in absorption or metabolism
• Use of alcohol or drug interactions

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Convulsive Seizure

• Category of impairments
• Major motor seizures (grand mal or psychomotor)
• Occuring gt 1 / month, in spite of at least 3
  months of prescribed treatment with
• Daytime episodes
• Nocturnal episodes with residuals ( significantly
  interfering with activity during the day)

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Convulsive Seizure

• Minor motor seizures (petit mal, psychomotor or
  focal)
• gt 1x / week in spite of at least 3 months of
  prescribed treatment
• With alteration of consciousness and transient
  postictal manifestations of conventional behavior
  or significant interference with activity during
  the day

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Vascular Accidents (gt 3 most postvascular
accident)

• Sensory or motor aphasia resulting in ineffective
  speech or communication or
• Significant or persistent disorganization of
  motor function in two extremities, resulting in
  sustained disturbances of gross and dexterous
  movements, or gait and station.
• Depends on the degree of interference with
  locomotion and/or interference with the use of
  fingers, hands and arms

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Brain Tumors

• Definitive diagnosis
• Histologically malignant tumor pathological
  diagnosis alone will be the decisive criterion
  for severity and expected duration
• Other tumors severity and duration of the
  impairment will be determined on the basis of
  symptoms, signs and pertinent laboratory findings
• Persistence of the tumor

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Brain tumors

• The site of primary, recurrent and metastatic
  lesion must be specified- in malignant neoplastic
  diseases
• Operative procedure or hospitalization with
  findings of surgery and results of pathologists
  gross and microscopic examination of tissues

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Brain Tumors

• Maligant gliomas( astrocytomas grades III-IV,
  glioblastoma multiforme) medulloblastoma,
  epenymoblastoma, primary sarcoma) or
• Astrosarcoma (grades I-II), meningioma, pituitary
  tumors, oligodendroglioma, epndymoma, clivus
  chordoma and benign tumors

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Brain Tumors

• Assessment based on
• Secondary Epilepsy, major or minor
• gt 3 months of
• Sensory or motor aphasia
• Significant or persistent disorganization of
  motor function
• Secondary mental disorders

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Parkinsonian syndrome

• Significant rigidity, bradykinesia or tremor in
  two extremities which singly or in combination,
  result in sustained disturbance of gross and
  dexterous movements, or gait and station

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Cerebral Palsy

• IQ of 70 or less or
• Abnormal behavior patterns, as destructive or
  emotional instability
• Significant interference in communication due to
  speech, hearing or visual defect or
• Disorganization of motor functions

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Spinal cord or nerve root lesions

• Disorganization of motor function

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Other Episodic conditions

• Multiple sclerosis/ myasthenia gravis
• Frequency and duration of exacerbation
• Length of remissions
• Permanent residuals

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Multiple Sclerosis

• I. Disorganization of motor function
• Significant and persistent disorganization of
  motor function in two extremities, resulting in
  sustained disturbance of gross and dexterous
  movements, or gait and station

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Multiple Sclerosis

• II. Visual impairments
• Impairment of central visual acuity
• Contraction of peripheral visual fields in the
  better eye
• Loss of visual efficiency

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Multiple Sclerosis

• III. Mental impairments
• History and PE or laboratory tests demonstrate
  the presence of a specific organic factor judged
  to be etiologically related to the abnormal
  mental state and loss of previously acquired
  functional abilities

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Multiple Sclerosis

• IV. Significant reproducible fatigue of motor
  function with substantial muscle weakness on
  repetitive activity, demonstrated of PE with CNS
  correlation
• - use of assessment scale
• - evoke response tests during exercise

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Myasthenia Gravis

• Significant difficulty with speaking, swallowing
  or breathing while on prescribed therapy or
• Significant motor weakness of muscles of
  extremities on repetitive activity against
  resistance while on prescribed therapy

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Amyotrophic lateral sclerosis

• Significant bulbar signs
• Disorganization of motor function

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Anterior Poliomyelitis

• Persistent difficulty with swallowing or
  breathing
• Unintelligible speech
• Disorganization of motor function

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Muscular Dystrophy

• Disorganization of motor function

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Tabes Dorsalis

• Tabetic crisis occuring more frequently than once
  monthly or
• Unsteady, broad based or ataxic gait causing
  significant restriction of mobility substantiated
  by appropriate posterior column signs

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Subacute combined cord Degeneration

• Disorganization of motor function, not
  significantly improved by prescribed treatment

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Degenerative disease(Huntingtons chorea,
Friedreichs ataxia, and Spino-cerebellar
degeneration, Alzhiemers dementia)

• Disorganization of motor function
• Chronic brain syndrome

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Traumatic Brain Injury

• May result in neurological and mental impairments
  with a wide variety of posttraumatic s/sx
• May need to defer adjudication of the claim at
  least 6 months post-injury

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Traumatic Brain Injury

• Evaluated according to
• Secondary seizure
• Secondary motor or sensory aphasia
• Significant or persistent disorganization of
  motor function
• Cognitive dysfunction

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