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Assessing Neurological Assessing Neurological DisabilityDisability
Corina Azores-Macalintal, M.D., F.P.N.ACorina Azores-Macalintal, M.D., F.P.N.A
QuestionsQuestions
When is the patient neurologically When is the patient neurologically disabled?disabled?
What kind of neurological disabilities does What kind of neurological disabilities does neurological diseases brings?neurological diseases brings?
DisabilityDisability
Definition: Definition: Inability to engage in any substantial gainful Inability to engage in any substantial gainful
activity by reason of any medically determined activity by reason of any medically determined physical or mental impairment(s) which can physical or mental impairment(s) which can be expected to result to death or which has be expected to result to death or which has lasted or can be expected to last for a lasted or can be expected to last for a continuous period of time.continuous period of time.
When is the patient neurologically When is the patient neurologically disabled?disabled?
Mental/ cognitiveMental/ cognitiveVisual / auditoryVisual / auditoryMotorMotorSensorySensoryBalance and CoordinationBalance and CoordinationGaitGait
Mental DisabilityMental Disability
Language dysfunction (Aphasia)Language dysfunction (Aphasia)Executive dysfunctionExecutive dysfunctionMemory dysfunctionMemory dysfunction
AphasiaAphasia
Acquired impairment of comprehension Acquired impairment of comprehension and production of verbal language caused and production of verbal language caused by brain damage.by brain damage.
Alexia and agraphia often co-exist with Alexia and agraphia often co-exist with aphasiaaphasia
AphasiaAphasia
Four areas of language functioningFour areas of language functioningAuditory comprehensionAuditory comprehensionRepetitionRepetitionFluency of verbal expressionFluency of verbal expressionConfrontation namingConfrontation naming
AphasiaAphasia
Non-fluentNon-fluent
Broca’sBroca’s Transcortical motorTranscortical motor GlobalGlobal Mixed TranscorticalMixed Transcortical
FluentFluent Wernicke’sWernicke’s Transcortical sensoryTranscortical sensory ConductionConduction AnomicAnomic
Auditory comprehensionAuditory comprehension
AsyntacticAsyntactic Can be asyntacticCan be asyntactic Severe impairment andSevere impairment and Retain prosodyRetain prosody
Like globalLike global Milder than globalMilder than global AsyntacticAsyntactic intactintact
AphasiaAphasia Non-fluentNon-fluent
Broca’sBroca’s Transcortical motorTranscortical motor GlobalGlobal Mixed TranscorticalMixed Transcortical
FluentFluent Wernicke’sWernicke’s Transcortical sensoryTranscortical sensory ConductionConduction AnomicAnomic
Verbal expressionVerbal expression
Agrammatism, aprosodia, apraxia of Agrammatism, aprosodia, apraxia of speech, poor repetitionspeech, poor repetition
Poor initiation, elaboration, intact Poor initiation, elaboration, intact repetition,echolaliarepetition,echolalia
Limited to automatisms, stereotypies, Limited to automatisms, stereotypies, poor repetitionpoor repetition
Limited spontaneous, intact repetition, Limited spontaneous, intact repetition, echolaliaecholalia
Nonmeaningful logorrhea, anosognosiaNonmeaningful logorrhea, anosognosia
Intact repetition, echolaliaIntact repetition, echolalia
Conduit d’approche, poor repetitionConduit d’approche, poor repetition
Pauses for word retrieval, intact Pauses for word retrieval, intact repetitionrepetition
AphasiaAphasia Non-fluentNon-fluent
Broca’sBroca’s Transcortical motorTranscortical motor GlobalGlobal Mixed TranscorticalMixed Transcortical
FluentFluent Wernicke’sWernicke’s Transcortical sensoryTranscortical sensory
ConductionConduction AnomicAnomic
Typical word retrieval Typical word retrieval errorserrors Semantic, verbs worse than nounsSemantic, verbs worse than nouns No response, perseverationsNo response, perseverations Stereotypies, semanticStereotypies, semantic Stereotypies, semanticStereotypies, semantic
Neogolisms, semantic, phonemicsNeogolisms, semantic, phonemics Semantic, phonemic, Semantic, phonemic,
circumlocutionscircumlocutions Phonemics, semanticPhonemics, semantic Circumlocutions, no response, Circumlocutions, no response,
semantic, nouns worse than verbssemantic, nouns worse than verbs
AphasiaAphasia Non-fluentNon-fluent
Broca’sBroca’s Transcortical motorTranscortical motor GlobalGlobal Mixed TranscorticalMixed Transcortical
FluentFluent Wernicke’sWernicke’s Transcortical sensoryTranscortical sensory
ConductionConduction AnomicAnomic
Left Hemisphere lesion Left Hemisphere lesion locationslocations Inf. Frontal, operculumInf. Frontal, operculum Dosolateral frontal, or thalamusDosolateral frontal, or thalamus Large pre-rolandic + post Large pre-rolandic + post
rolandicrolandic Watershed/ extrasylvian cortexWatershed/ extrasylvian cortex
Superior temporalSuperior temporal Temoral-parietal or Temoral-parietal or
degenerativedegenerative
Parietal, insulaParietal, insula Inferior temporal or thalamus or Inferior temporal or thalamus or
degenerativedegenerative
Executive DysfunctionExecutive Dysfunction
Impairments in initiation, intention, Impairments in initiation, intention, planning, sequencing, inhibition, flexibility, planning, sequencing, inhibition, flexibility, monitoring and various complex aspects of monitoring and various complex aspects of attentionattention
Memory DysfunctionMemory Dysfunction
MCIMCIDementiaDementia
DementiaDementia
Memory impairment (learning and recall)Memory impairment (learning and recall)One or more:One or more:
AphasiaAphasiaApraxiaApraxiaAgnosiaAgnosiaDysexecutive function (planning, organizing, Dysexecutive function (planning, organizing,
sequencing, abstracting)sequencing, abstracting)*** deficits of sufficient severity to affect social *** deficits of sufficient severity to affect social
or occupational functioningor occupational functioning
Limb ApraxiaLimb Apraxia
Impaired ability to perform skilled, Impaired ability to perform skilled, purposeful limb movements as a result of purposeful limb movements as a result of neurologic dysfunctionneurologic dysfunction ***excluding weakness, akinesia, ***excluding weakness, akinesia,
abnormalities of tone or posture and abnormalities of tone or posture and movement disordersmovement disorders
Limb ApraxiaLimb Apraxia
TypeType
Limb-kineticLimb-kinetic
IdeomotorIdeomotor
IdeationalIdeational
conceptualconceptual
Clinical featuresClinical features
Impaired ability to make finem Impaired ability to make finem precise, independent finger precise, independent finger movementsmovements
Gesture production errorsGesture production errors
Impaired sequencing of tool Impaired sequencing of tool useuse
Content errors in tool use, Content errors in tool use, errors in tool selectionerrors in tool selection
Limb ApraxiaLimb Apraxia
TypeType
Limb-kineticLimb-kinetic
IdeomotorIdeomotor
IdeationalIdeational
conceptualconceptual
Assessment tasksAssessment tasks
Rotate coin between Rotate coin between thumb and fingersthumb and fingers
Gesture to command, Gesture to command, gesture imitationgesture imitation
Serial acts (e.g. fold Serial acts (e.g. fold letter place in letter place in envelope, seal, stamp)envelope, seal, stamp)
Tool-object matching Tool-object matching (hammer and nail)(hammer and nail)
Assessment ToolsAssessment Tools
Mini Mental State ExaminationMini Mental State Examination(MMSE)(MMSE)
OrientationOrientationRegistrationRegistrationAttention and CalculationAttention and CalculationRecallRecallLanguageLanguage
Neuropsychological TestingNeuropsychological Testing
Comprehensive examinations may be Comprehensive examinations may be used to establish the existence and extent used to establish the existence and extent of compromise of brain functionof compromise of brain function
Neuropsychological TestingNeuropsychological Testing
Cerebral dominanceCerebral dominance basic sensation and basic sensation and
perceptionperception motor speed and motor speed and
coordination,coordination, attention and attention and
concentration,concentration, visual-motor functionvisual-motor function memory across verbal memory across verbal
and visual modalitiesand visual modalities
Receptive and expressive Receptive and expressive speechspeech
Higher-order linguistic Higher-order linguistic operationsoperations
Problem-solvingProblem-solving Abstraction abilityAbstraction ability General intelligenceGeneral intelligence
Neuropsychological TestingNeuropsychological Testing
Should include evaluating pathological Should include evaluating pathological features as:features as:Emotional labilityEmotional labilityAbnormality of moodAbnormality of mood Impaired impulse controlImpaired impulse controlPassivity and apathyPassivity and apathy Inappropriate social behaviorInappropriate social behavior
Criteria for Criteria for Organic Mental DisorderOrganic Mental Disorder
A. Loss of specific cognitive abilities and medically A. Loss of specific cognitive abilities and medically
documented persistencedocumented persistence of at least one of the FF:of at least one of the FF:
Disorientation to time and place, orDisorientation to time and place, or Memory impairment (short-term, intermediate, or long-Memory impairment (short-term, intermediate, or long-
term), orterm), or Perceptual or thinking disturbances (e.g. hallucinations, Perceptual or thinking disturbances (e.g. hallucinations,
delusions, ordelusions, or Change in personality, orChange in personality, or Disturbance in mood, orDisturbance in mood, or Emotional lability (e.g. explosive temper outbursts, Emotional lability (e.g. explosive temper outbursts,
sudden crying…) and impairment of impulse controlsudden crying…) and impairment of impulse control Loss of measured intellectual ability of at least 15 I.Q Loss of measured intellectual ability of at least 15 I.Q
points from premorbid levels or severely impaired range points from premorbid levels or severely impaired range on neuropsychological testingon neuropsychological testing
And B. Resulting in at least two And B. Resulting in at least two of the followingof the following
Marked restriction of activities of daily Marked restriction of activities of daily living; orliving; or
Marked difficulties in maintaining social Marked difficulties in maintaining social functioning; orfunctioning; or
Marked difficulties in maintaining Marked difficulties in maintaining concentration, persistence, or pace; orconcentration, persistence, or pace; or
Repeated episodes of decompensation, Repeated episodes of decompensation, each of extended durationeach of extended duration
OrOr C. Medically documented history of chronic C. Medically documented history of chronic organic mental disorder of at least 2 years organic mental disorder of at least 2 years
and one of the following:and one of the following:
Repeated episodes of decompensation, Repeated episodes of decompensation, each of extended durationeach of extended duration
A residual disease process that has A residual disease process that has resulted in such marginal adjustment that resulted in such marginal adjustment that even a minimal increase in mental even a minimal increase in mental demands or change in the environment demands or change in the environment would be predicted to cause the individual would be predicted to cause the individual to decompensateto decompensate
Current history of 1 or more years’ inability Current history of 1 or more years’ inability to function outside a highly supportive to function outside a highly supportive living arrangement, with an indication of living arrangement, with an indication of continued need for such an arrangementcontinued need for such an arrangement
VisualVisual
Presentations:Presentations: Visual loss/blurringVisual loss/blurring Visual field defects Visual field defects
(anopsia)(anopsia)
AssessmentAssessment Field testingField testing FundoscopyFundoscopy Visual acuity test Visual acuity test
(Snellen)(Snellen) VEPVEP
auditoryauditory
Presentation:Presentation: DeafnessDeafness TinnitusTinnitus DizzinessDizziness
AssessmentAssessment Weber, Rinne’sWeber, Rinne’s AudiogramAudiogram BAERBAER
Motor, sensory, balance, coordination and Motor, sensory, balance, coordination and gait disabilitiesgait disabilities
= disorganization of motor function= disorganization of motor function
Disorganization of Motor functionDisorganization of Motor function
In the form of paresis or paralysis, tremor In the form of paresis or paralysis, tremor or other involuntary movements, ataxia, or other involuntary movements, ataxia, sensory disturbances which may occur sensory disturbances which may occur singly or in various combinationssingly or in various combinations
Disorganization of Motor functionDisorganization of Motor function
Assessment of impairment depends on the Assessment of impairment depends on the degree of interference with locomotion degree of interference with locomotion and/or interference with the use of fingers, and/or interference with the use of fingers, hands and arms.hands and arms.
AssessmentAssessment
Motor StrengthMotor StrengthSensory Sensory
Light touch, pressure, heat / cold, Light touch, pressure, heat / cold, proprioceptionproprioception
*** abnormal sensation as dysaesthesia, *** abnormal sensation as dysaesthesia, allodynia, hyperaesthesiaallodynia, hyperaesthesia
AssessmentAssessment
Balance, coordination and gaitBalance, coordination and gaitFinger to nose test / heal to shin testFinger to nose test / heal to shin testTandem walkingTandem walking
Category of Category of Neurological ImpairmentsNeurological Impairments
Convulsive SeizureConvulsive Seizure
Degree of impairment Degree of impairment Determined according to type, frequency, Determined according to type, frequency,
duration and sequelaeduration and sequelaeAt least 1 detailed description of a typical At least 1 detailed description of a typical
seizureseizurePresence of associated signs/ symptomsPresence of associated signs/ symptomsDocumentation with at least 1 EEGDocumentation with at least 1 EEG
Convulsive seizureConvulsive seizure
Only if impairment persists despite Only if impairment persists despite treatmenttreatmentBlood levels of anticonvulsant medicationsBlood levels of anticonvulsant medications
Compliance to anticonvulsant medicationCompliance to anticonvulsant medicationIdiosyncrasy in absorption or metabolismIdiosyncrasy in absorption or metabolism
Use of alcohol or drug interactionsUse of alcohol or drug interactions
Convulsive SeizureConvulsive Seizure
Category of impairments:Category of impairments:Major motor seizures: (grand mal or Major motor seizures: (grand mal or
psychomotor)psychomotor)Occuring > 1 / month, in spite of at least 3 months Occuring > 1 / month, in spite of at least 3 months
of prescribed treatment with:of prescribed treatment with: Daytime episodesDaytime episodes Nocturnal episodes with residuals ( significantly Nocturnal episodes with residuals ( significantly
interfering with activity during the day)interfering with activity during the day)
Convulsive SeizureConvulsive Seizure
Minor motor seizures: (petit mal, psychomotor Minor motor seizures: (petit mal, psychomotor or focal)or focal)> 1x / week in spite of at least 3 months of > 1x / week in spite of at least 3 months of
prescribed treatmentprescribed treatmentWith alteration of consciousness and transient With alteration of consciousness and transient
postictal manifestations of conventional behavior postictal manifestations of conventional behavior or significant interference with activity during the or significant interference with activity during the dayday
Vascular AccidentsVascular Accidents (> 3 most post=vascular accident)(> 3 most post=vascular accident)
Sensory or motor aphasia resulting in Sensory or motor aphasia resulting in ineffective speech or communication; orineffective speech or communication; or
Significant or persistent disorganization of Significant or persistent disorganization of motor function in two extremities, resulting motor function in two extremities, resulting in sustained disturbances of gross and in sustained disturbances of gross and dexterous movements, or gait and station.dexterous movements, or gait and station.Depends on the degree of interference with Depends on the degree of interference with
locomotion and/or interference with the use of locomotion and/or interference with the use of fingers, hands and armsfingers, hands and arms
Brain TumorsBrain Tumors
Definitive diagnosisDefinitive diagnosisHistologically malignant tumor – pathological Histologically malignant tumor – pathological
diagnosis alone will be the decisive criterion diagnosis alone will be the decisive criterion for severity and expected durationfor severity and expected duration
Other tumors – severity and duration of the Other tumors – severity and duration of the impairment will be determined on the basis of impairment will be determined on the basis of symptoms, signs and pertinent laboratory symptoms, signs and pertinent laboratory findingsfindings
Persistence of the tumorPersistence of the tumor
Brain tumorsBrain tumors
The site of primary, recurrent and The site of primary, recurrent and metastatic lesion must be specified- in metastatic lesion must be specified- in malignant neoplastic diseasesmalignant neoplastic diseases
Operative procedure or hospitalization with Operative procedure or hospitalization with findings of surgery and results of findings of surgery and results of pathologist’s gross and microscopic pathologist’s gross and microscopic examination of tissuesexamination of tissues
Brain TumorsBrain Tumors
Maligant gliomas( astrocytomas grades III-Maligant gliomas( astrocytomas grades III-IV, glioblastoma multiforme) IV, glioblastoma multiforme) medulloblastoma, epenymoblastoma, medulloblastoma, epenymoblastoma, primary sarcoma) orprimary sarcoma) or
Astrosarcoma (grades I-II), meningioma, Astrosarcoma (grades I-II), meningioma, pituitary tumors, oligodendroglioma, pituitary tumors, oligodendroglioma, epndymoma, clivus chordoma and benign epndymoma, clivus chordoma and benign tumorstumors
Brain TumorsBrain Tumors
Assessment based on:Assessment based on:Secondary Epilepsy, major or minorSecondary Epilepsy, major or minor> 3 months of> 3 months of
Sensory or motor aphasiaSensory or motor aphasiaSignificant or persistent disorganization of motor Significant or persistent disorganization of motor
functionfunction
Secondary mental disordersSecondary mental disorders
Parkinsonian syndromeParkinsonian syndrome
Significant rigidity, bradykinesia or tremor Significant rigidity, bradykinesia or tremor in two extremities which singly or in in two extremities which singly or in combination, result in sustained combination, result in sustained disturbance of gross and dexterous disturbance of gross and dexterous movements, or gait and stationmovements, or gait and station
Cerebral PalsyCerebral Palsy
IQ of 70 or less; orIQ of 70 or less; orAbnormal behavior patterns, as Abnormal behavior patterns, as
destructive or emotional instabilitydestructive or emotional instabilitySignificant interference in communication Significant interference in communication
due to speech, hearing or visual defect; ordue to speech, hearing or visual defect; orDisorganization of motor functionsDisorganization of motor functions
Spinal cord or nerve root lesionsSpinal cord or nerve root lesions
Disorganization of motor functionDisorganization of motor function
Other Episodic conditionsOther Episodic conditions
Multiple sclerosis/ myasthenia gravisMultiple sclerosis/ myasthenia gravisFrequency and duration of exacerbationFrequency and duration of exacerbationLength of remissionsLength of remissionsPermanent residualsPermanent residuals
Multiple SclerosisMultiple Sclerosis
I. Disorganization of motor functionI. Disorganization of motor functionSignificant and persistent disorganization of Significant and persistent disorganization of
motor function in two extremities, resulting in motor function in two extremities, resulting in sustained disturbance of gross and dexterous sustained disturbance of gross and dexterous movements, or gait and stationmovements, or gait and station
Multiple SclerosisMultiple Sclerosis
II. Visual impairmentsII. Visual impairments Impairment of central visual acuityImpairment of central visual acuityContraction of peripheral visual fields in the Contraction of peripheral visual fields in the
better eyebetter eyeLoss of visual efficiencyLoss of visual efficiency
Multiple SclerosisMultiple Sclerosis
III. Mental impairmentsIII. Mental impairmentsHistory and PE or laboratory tests History and PE or laboratory tests
demonstrate the presence of a specific demonstrate the presence of a specific organic factor judged to be etiologically organic factor judged to be etiologically related to the abnormal mental state and loss related to the abnormal mental state and loss of previously acquired functional abilitiesof previously acquired functional abilities
Multiple SclerosisMultiple Sclerosis
IV. Significant reproducible fatigue of motor IV. Significant reproducible fatigue of motor function with substantial muscle weakness function with substantial muscle weakness on repetitive activity, demonstrated of PE on repetitive activity, demonstrated of PE with CNS correlationwith CNS correlation
- use of assessment scale- use of assessment scale
- evoke response tests during - evoke response tests during exerciseexercise
Myasthenia GravisMyasthenia Gravis
Significant difficulty with speaking, Significant difficulty with speaking, swallowing or breathing while on swallowing or breathing while on prescribed therapy; orprescribed therapy; or
Significant motor weakness of muscles of Significant motor weakness of muscles of extremities on repetitive activity against extremities on repetitive activity against resistance while on prescribed therapyresistance while on prescribed therapy
Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis
Significant bulbar signsSignificant bulbar signsDisorganization of motor functionDisorganization of motor function
Anterior PoliomyelitisAnterior Poliomyelitis
Persistent difficulty with swallowing or Persistent difficulty with swallowing or breathingbreathing
Unintelligible speechUnintelligible speechDisorganization of motor functionDisorganization of motor function
Muscular DystrophyMuscular Dystrophy
Disorganization of motor functionDisorganization of motor function
Tabes DorsalisTabes Dorsalis
Tabetic crisis occuring more frequently Tabetic crisis occuring more frequently than once monthly; orthan once monthly; or
Unsteady, broad based or ataxic gait Unsteady, broad based or ataxic gait causing significant restriction of mobility causing significant restriction of mobility substantiated by appropriate posterior substantiated by appropriate posterior column signscolumn signs
Subacute combined cord Subacute combined cord DegenerationDegeneration
Disorganization of motor function, not Disorganization of motor function, not significantly improved by prescribed significantly improved by prescribed treatmenttreatment
Degenerative diseaseDegenerative disease(Huntington’s chorea, Friedreich’s ataxia, and Spino-(Huntington’s chorea, Friedreich’s ataxia, and Spino-
cerebellar degeneration, Alzhiemer’s dementia…)cerebellar degeneration, Alzhiemer’s dementia…)
Disorganization of motor functionDisorganization of motor functionChronic brain syndromeChronic brain syndrome
Traumatic Brain InjuryTraumatic Brain Injury
May result in neurological and mental May result in neurological and mental impairments with a wide variety of impairments with a wide variety of posttraumatic s/sxposttraumatic s/sx
May need to defer adjudication of the May need to defer adjudication of the claim at least 6 months post-injuryclaim at least 6 months post-injury
Traumatic Brain InjuryTraumatic Brain Injury
Evaluated according to:Evaluated according to:Secondary seizureSecondary seizureSecondary motor or sensory aphasiaSecondary motor or sensory aphasiaSignificant or persistent disorganization of Significant or persistent disorganization of
motor functionmotor functionCognitive dysfunctionCognitive dysfunction