assessing neurological disability corina azores-macalintal, m.d., f.p.n.a

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


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



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



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


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


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


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


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


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)


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


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


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


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


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


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

assessing neurological disability corina azores-macalintal, m.d., f.p.n.a

Documents

aphasia slide

intact repetition slide

aphasia alexia

anosognosia intact repetition

impairment of comprehension

poor repetition pauses

production of verbal

coordination gait gait