Can I Get Social Security Disability Benefits for Anxiety, Phobias, Panic Attacks, Obsessive Compulsive Disorder (OCD), or Post-Traumatic Stress Disorder (PTSD)?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for an Anxiety Disorder?
• About Anxiety Disorders and Disability
• Winning Social Security Disability Benefits for an Anxiety Disorder by Meeting a Listing
• Residual Functional Capacity Assessment for Anxiety Disorders
• Getting Your Doctor’s Medical Opinion About What You Can Still Do

How Does the Social Security Administration Decide if I Qualify for Disability Benefits for an Anxiety Disorder?

If you have an anxiety disorder, Social Security disability benefits may be available. To determine whether you are disabled by your anxiety disorder, Social Security Administration first considers whether it is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Anxiety Disorders by Meeting a Listing. If you meet or equal a listing because of your anxiety, you are considered disabled. If your anxiety disorder is not severe enough to equal or meet a listing, Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite the anxiety disorder), to determine whether you qualify for disability benefits at Step 4 and Step 5 Sequential Evaluation Process. See

Residual Functional Capacity Assessment for Anxiety

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About Anxiety Disorders and Disability

What Are Anxiety Disorders?

Anxiety is fear associated with the expectation of being physically or mentally injured by some real or imagined danger. Anxiety disorders include:

• Generalized anxiety disorder;
• Various phobic disorders (simple phobia, social phobia, agoraphobia)
• Panic disorder
• Obsessive compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)

Anxiety is common in the U.S., as evidenced by the literally tons of tranquilizers given yearly in legal prescription drugs. Probably the most frequent mental disability allegation is “nerves,” by which the claimant means anxiety.

Information from Family and Friends Is Crucial to Disability Determination

Claimants with mental disorders living with family members are most likely to be improperly denied by Social Security Administration adjudicators. It is critically important for family members or other caregivers to provide the Social Security Administration with as detailed information as possible about specific tasks you can or cannot do.

Mental health clinics will often refuse to provide the Social Security Administration with clinical records that are useful in evaluating how a mental disorder has developed over time. They might simply write a letter summarizing what they think they Social Security Administration needs to know. In some instances, the Social Security Administration is forced to fall back on purchasing a consultative mental status examination in which the examining psychiatrist or psychologist has limited time to determine the details of daily functional capacity. The Social Security Administration should ask the treating psychiatrist (or psychologist) about work-related abilities for at least unskilled work and how these conclusions match with the corresponding limiting mental symptom.

If you are receiving medication, information about side-effects must come from a medical doctor, because a psychologist is not competent to evaluate that matter. However, it is also important for the same kind of information and opinions to be obtained from family or other caregivers, to make sure that nothing is missed. The caregivers live with the claimant; they may have noticed important facts that can be brought to the attention of the treating psychiatrist and the Social Security Administration.

Winning Social Security Disability Benefits for an Anxiety Disorder by Meeting a Listing

To determine whether you are disabled at Step 3of the Sequential Evaluation Process, the Social Security Administration will consider whether your anxiety disorder is severe enough to meet or equal the anxiety-related disorders listing. The Social Security Administration has developed rules called Listing of Impairmentsfor 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 anxiety disorder is severe enough to meet or equal the listing, you will be considered disabled. But anxiety is rarely incapacitating at listing-level severity.

The listing for anxiety disorders is 12.03. This listing applies when either (1) anxiety is the predominant disturbance or (2) anxiety is experienced if you attempt to master symptoms, for example, confronting the dreaded object or situation in a phobic disorder or resisting the obsessions or compulsions in obsessive compulsive disorders.

The listing has 3 parts: A, B, and C. To meet the listing, you must satisfy both parts A and B or both parts A and C.

Meeting Social Security Administration Listing 12.06A for Anxiety Disorders

To meet listing 12.06A you must have medically documented findings of at least one of the following:

1. Generalized persistent anxiety accompanied by three out of four of the following signs or symptoms:

a. Motor tension; or

b. Autonomic hyperactivity; or

c. Apprehensive expectation; or

d. Vigilance and scanning; or

2. A persistent irrational fear of a specific object, activity, or situation which results in a compelling desire to avoid the dreaded object, activity, or situation; or

3. Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension, fear, terror and sense of impending doom occurring on the average of at least once a week; or

4. Recurrent obsessions or compulsions which are a source of marked distress; or

5. Recurrent and intrusive recollections of a traumatic experience, which are a source of marked distress.

Part A.1 Generalized Anxiety Disorder

Part A.1 deals with generalized anxiety disorder, which is a common mental disorder. It rarely produces more than mild impairment in functioning, but there are exceptions. Any three of the criteria Part A.1.a through d must be fulfilled.

• Part A.1.a deals with “motor tension.” This refers to the observable physical expression of anxiety, e.g., restlessness, jumpiness, trembling, fidgeting, strained appearance to the face, and the feeling that one is “uptight” and cannot relax. Such a person appears “nervous.”
• Part A.1.b deals with “autonomic hyperactivity.” Autonomic functions are those automatic functions carried out by the body that are not usually under conscious control. In anxiety there is increased activation of the sympathetic nervous system, preparing the body for impending physical stress. This reaction is normal if a person faces a serious threat that calls for a decision to “fight or run.” But in inappropriate anxiety, autonomic arousal exceeds the real degree of threat. Hormones are released (epinephrine and norepinephrine from the adrenal glands) which increase the rate and force of heartbeat, and raise the blood pressure. The mouth may feel dry and the stomach queasy. There is increased sweating (“clammy hands”) and faster breathing. A sustained condition of sympathetic autonomic arousal is not healthy for the body, and not comfortable for the person experiencing it. In fact, studies have demonstrated that cortisol released during stress impairs memory and other cognitive functions by adverse effect on the hippocampus in the brain. Chronic stress may permanently injure the brain, although this is not a theory that can easily be tested.
• Part A.1.c deals with “apprehensive expectation.” This state involves a preoccupation with possible negative events, either for oneself or others. Such a person worries excessively and is in continuous anticipation of something going wrong without any significant indication of a realistic threat, i.e., it is a continuous state of fear.
• Part A.1.d deals with “vigilance and scanning,” which are a result of apprehensive expectation. The environment is scanned with hyper-attentiveness, so that threats cannot approach unseen. This state would be appropriate for a soldier moving through the jungle looking for booby traps, but not when the threat is unreal. If a threat cannot be selectively and realistically identified, then there is the possibility it may approach anywhere at any time. Such a person constantly feels “on edge,” irritable, distractible, and has sleep disturbance which provides inadequate rest.

Part A.2 Phobias

Part A.2 deals with phobias, and defines phobia as, “A persistent irrational fear of a specific object, activity, or situation which results in a compelling desire to avoid the dreaded object, activity, or situation.” The word “irrational” is important. Realistic fears of things that can produce harm are not phobias.

Agoraphobia may be an irrational fear of being alone, or fear of being away from home in some public place. The individual does not feel “safe” and fear of being in crowds is one of the most common forms. Severe agoraphobia understandably produces marked restriction of activities and interests to those that can be performed in the home, though the condition may wax and wane in severity. Marked agoraphobia is the most frequent type of phobia qualifying under part A.2.

A person with social phobia has an irrational fear of social situations, manifested by desire to avoid circumstances in which interaction with other people is possible. The person fears being perceived as in some way inferior with consequent humiliation or embarrassment, and, as a consequence, avoids social situations. The disorder is uncommon and usually not incapacitating. An example might be an extreme fear of public speaking. If the disorder causes fear of a large number of possible social situations, then severe functional impairment would result.

With simple phobia or specific phobia, the person has a highly specific fear. Examples might be fear of heights, closed places, or certain animals. The degree of functional loss depends on how easy it is to avoid the phobic object. If a person feared volcanoes, it would not be difficult to avoid them. On the other hand, fear of airplanes or automobiles might have more serious functional consequences. Most simple phobias are not very limiting functionally, because the dreaded object can be easily avoided.

Part A.3 Panic Disorder

Part A.3 deals with panic disorder. Panic disorder is characterized by the sudden, usually unpredictable, and very intense feeling of anxiety, fear, terror or impending doom. Accompanying effects are autonomic sympathetic arousal associated with anxiety and fear, such as sweating, palpitations, and trembling. Attacks usually only last a few minutes, and in some cases may play a role in the development of agoraphobia. The disorder is common, but not functionally incapacitating unless the individual suffers from unusually frequent or prolonged attacks.

Part A.3 requires an attack frequency of at least once a week on the average. If you have a panic disorder and are considering filing for disability benefits, it would be helpful to your claim to keep a detailed diary of your attacks and make sure that your treating physician has that information documented in medical records.

Part A.4 Obsessive Compulsive Disorder (OCD)

Part A.4 deals with obsessive compulsive disorder (OCD). Obsessions are persistent thoughts or ideas that enter the mind involuntarily, and are considered as either meaningless or repulsive to the person’s viewpoint. The most frequent obsessive thoughts involve violence, fear of contamination (especially the hands), and doubt (repeatedly wondering if some action was performed [such as locking a door], or whether some event took place).

Compulsions are repetitive behaviors, done either by some set of rules or always done in the same way. Although the compulsive behavior may appear to have purpose in and of itself, that is not the reason for its performance. Rather, the purpose of compulsion is to relieve the discomfort of obsession by either creating or preventing some future event. For example, in compulsive hand washing there is rational meaning in keeping the hands clean. But it is not rational if done excessively and/or to keep airplanes flying. Counting is a common form of compulsion, e.g., a person always feels compelled to count the lines on a sidewalk. Repeated checking and touching of things are also common forms of compulsion, as well as praying.

Attempts to resist a compulsion result in increased anxiety that is temporarily relieved if the person yields to the compulsion. Eventually, the person may give up attempts at resistance to prevent anxiety, though the compulsive activity itself may not be pleasurable. Activities such as “compulsive gambling” are not compulsions in the above sense, as the participant derives pleasure from such action, and seeks it out specifically as a source of satisfaction.

Functional incapacitation from obsessive compulsive disorder is not common, but it is a serious disorder and some cases qualify under part A.4. However, no cure is available and stopping medication will result in a relapse rate exceeding 90%. Onset of OCD is usually in the 20s or 30s with some degree of familial predisposition, and equally affecting men and women. Current drug and other therapies do not result in a complete relief of symptoms, although there is often substantial improvement. The disorder is associated both with abnormal brain chemistry and with abnormal anatomical circuits involving the frontal lobes, basal ganglia, and probably other structures. Over half of individuals with OCD have a second mental disorder.

The Social Security Administration should not assume that a newly diagnosed case of OCD will respond to medication. A decision should either be favorable or deferred until treatment response can be evaluated.

Part A.5 Post-Traumatic Stress Disorder (PTSD)

Part A.5 deals with post-traumatic stress disorder (PTSD). Part A.5 defines PTSD briefly as, “recurrent and intrusive recollections of a traumatic experience, which are a source of marked distress.” The traumatic experience is one that realistically could cause substantial psychological stress on most people. Examples are events like war, torture, concentration camp experience, natural disasters, or grievous physical injury in an accident. Less devastating events such as divorce or failure in a business would not qualify as precipitating events.

Physical surroundings similar to those of the traumatic event may trigger painful recollections, or they may come in the form of dreams and nightmares. Accompanying anxiety and depression are frequently present, as well as a feeling of emotional “numbness” or sense of being detached from others that impairs interpersonal relationships (especially in emotional responsiveness), and blunts interests in activities previously considered pleasurable or worthwhile. The disorder may be acute or chronic, and any degree of severity. Those cases severe enough to qualify under the listing tend to be well-documented with substantial medical evidence available to the Social Security Administration for review.

Meeting Social Security Administration Listing 12.06B for Anxiety Disorders

To meet part B of the anxiety disorders listing, you must satisfy the requirements of part A and, as a result of those impairments have at least two of the following:

1. Marked restriction of activities of daily living; or

2. Marked difficulties in maintaining social functioning; or

3. Marked difficulties in maintaining concentration, persistence, or pace; or

4. Repeated episodes of decompensation, each of extended duration.

Information Needed To Assess Part B

Here is what Social Security Administration says about the information needed to assess whether part B of the listing is met:

Assessment of Severity

: We measure severity according to the functional limitations imposed by your medically determinable mental impairment(s). We assess functional limitations using the four criteria in paragraph B of the listings: activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation. Where we use “marked” as a standard for measuring the degree of limitation, it means more than moderate but less than extreme. A marked limitation may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with your ability to function independently, appropriately, effectively, and on a sustained basis. See §§404.1520a and 416.920a.

1. Activities of daily living

include adaptive activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for your grooming and hygiene, using telephones and directories, and using a post office. In the context of your overall situation, we assess the quality of these activities by their independence, appropriateness, effectiveness, and sustainability. We will determine the extent to which you are capable of initiating and participating in activities independent of supervision or direction.

We do not define “marked” by a specific number of activities of daily living in which functioning is impaired, but by the nature and overall degree of interference with function. For example, if you do a wide range of activities of daily living, we may still find that you have a marked limitation in your daily activities if you have serious difficulty performing them without direct supervision, or in a suitable manner, or on a consistent, useful, routine basis, or without undue interruptions or distractions.

2. Social functioning

refers to your capacity to interact independently, appropriately, effectively, and on a sustained basis with other individuals. Social functioning includes the ability to get along with others, such as family members, friends, neighbors, grocery clerks, landlords, or bus drivers. You may demonstrate impaired social functioning by, for example, a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or social isolation. You may exhibit strength in social functioning by such things as your ability to initiate social contacts with others, communicate clearly with others, or interact and actively participate in group activities. We also need to consider cooperative behaviors, consideration for others, awareness of others’ feelings, and social maturity. Social functioning in work situations may involve interactions with the public, responding appropriately to persons in authority (e.g., supervisors), or cooperative behaviors involving coworkers.

We do not define “marked” by a specific number of different behaviors in which social functioning is impaired, but by the nature and overall degree of interference with function. For example, if you are highly antagonistic, uncooperative, or hostile but are tolerated by local storekeepers, we may nevertheless find that you have a marked limitation in social functioning because that behavior is not acceptable in other social contexts.

3. Concentration, persistence and pace

refer to the ability to sustain focused attention and concentration long enough to permit the timely and appropriate completion of tasks commonly found in work settings. Limitations in concentration, persistence, or pace are best observed in work settings, but may also be reflected by limitations in other settings. In addition, major limitations in this area can often be assessed through clinical examination or psychological testing. Wherever possible, however, a mental status examination or psychological test data should be supplemented by other available evidence.

On mental status examinations, concentration is assessed by tasks such as having you subtract serial sevens or serial threes from 100. In psychological tests of intelligence or memory, concentration is assessed through tasks requiring short-term memory or through tasks that must be completed within established time limits.

In work evaluations, concentration, persistence, or pace is assessed by testing your ability to sustain work using appropriate production standards, in either real or simulated work tasks (e.g., filing index cards, locating telephone numbers, or disassembling and reassembling objects). Strengths and weaknesses in areas of concentration and attention can be discussed in terms of your ability to work at a consistent pace for acceptable periods of time and until a task is completed, and your ability to repeat sequences of action to achieve a goal or an objective.

We must exercise great care in reaching conclusions about your ability or inability to complete tasks under the stresses of employment during a normal workday or workweek based on a time-limited mental status examination or psychological testing by a clinician, or based on your ability to complete tasks in other settings that are less demanding, highly structured, or more supportive. We must assess your ability to complete tasks by evaluating all the evidence, with an emphasis on how independently, appropriately, and effectively you are able to complete tasks on a sustained basis.

We do not define “marked” by a specific number of tasks that you are unable to complete, but by the nature and overall degree of interference with function. You may be able to sustain attention and persist at simple tasks but may still have difficulty with complicated tasks. Deficiencies that are apparent only in performing complex procedures or tasks would not satisfy the intent of this paragraph B criterion. However, if you can complete many simple tasks, we may nevertheless find that you have a marked limitation in concentration, persistence, or pace if you cannot complete these tasks without extra supervision or assistance, or in accordance with quality and accuracy standards, or at a consistent pace without an unreasonable number and length of rest periods, or without undue interruptions or distractions.

4. Episodes of decompensation

are exacerbations or temporary increases in symptoms or signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing activities of daily living, maintaining social relationships, or maintaining concentration, persistence, or pace. Episodes of decompensation may be demonstrated by an exacerbation in symptoms or signs that would ordinarily require increased treatment or a less stressful situation (or a combination of the two). Episodes of decompensation may be inferred from medical records showing significant alteration in medication; or documentation of the need for a more structured psychological support system (e.g., hospitalizations, placement in a halfway house, or a highly structured and directing household); or other relevant information in the record about the existence, severity, and duration of the episode.

The term repeated episodes of decompensation, each of extended durationin these listings means three episodes within 1 year, or an average of once every 4 months, each lasting for at least 2 weeks. If you have experienced more frequent episodes of shorter duration or less frequent episodes of longer duration, we must use judgment to determine if the duration and functional effects of the episodes are of equal severity and may be used to substitute for the listed finding in a determination of equivalence.

Providing the Social Security Administration With Adequate Information

It is not easy for the Social Security Administration adjudicator to obtain quality, detailed information for use in part B of the listing. Treating psychiatrists often will not provide actual treatment records and when they do, the records often lack the detail needed to make an accurate determination regarding daily activities, social functioning, or concentration, persistence or pace. Medical records are more likely to document part B.4, because treatment notes or hospitalization records will record a change in the claimant’s condition.

The best evidence of functional ability comes from the claimant’s family or other caregivers, because they actually observe the claimant’s limitations and abilities, unlike the treating doctor. The doctor often merely guesses based on the claimant’s clinical condition.

Most psychiatrists and psychologists have only a general knowledge of their patient’s functional activities. But the treating doctor’s answers to questions about functional limitations may not always help the claimant. For example the doctor may be asked whether a claimant is limited in ability to perform a particular activity like take public transportation. If the doctor answers “Not that I know of,” this answer indicates ignorance and should not be taken as evidence of ability. But if the doctor answers, “I know of no mental limitation that would restrict the claimant’s ability to take public transportation,” then that informs Social Security Administration that the doctor thinks the claimant has the ability, even though the doctor may have no direct information to that effect.

Often, the Social Security Administration adjudicator will try to use daily activity, social information, etc., from a mental status consultative examination. This information often lacks enough detail for good disability determination.

It is important for the adjudicator to try to obtain a detailed specific description of daily activities, social functioning, task completion (concentration, persistence, or pace) and the circumstances surrounding episodes of decompensation. This means documentation of as many specific examples as possible; generalizations such as “He cannot do anything” are worthless. The daily activity forms that claimants or their caregivers complete are rarely specific enough to be of much use. To get high-quality information, the adjudicator must often contact the claimant or caregivers. This is a grueling, time-consuming job that requires an hour or more of communication. Furthermore, disability examiners have no skills in psychiatric interviewing even when they do attempt to get detailed information regarding part B, so that is an additional source of error. Therefore, inadequate development of part B information by the Social Security Administration in mental disorder claims is a weak spot and one reason a claimant may be denied disability benefits.

Meeting Social Security Administration Listing 12.03C for Anxiety Disorders

If you meet part A of the listing, but do not meet part B of the listing, you will be disabled if you meet part C. Part C requires that the impairments in part A result in your complete inability to function independently outside the area of your home.

Part C concerns functional severity and recognizes the incapacitation of claimants who can function inside their homes, but who suffer severe anxiety outside the home. This limitation is incompatible with the ability to perform job functions. You can qualify under part C even though you have fairly normal interests and activities within the structured and less anxiety-provoking home environment. The medical evidence needed is a description of the anxiety provoked when attempts are made to leave the home, as well as the nature and manner in which symptoms inhibit activities outside the home (such as shopping or visiting friends). Note that the listing requires complete inability to function independently outside the area of one’s home. This means you would not only suffer inhibiting anxiety outside the home, but as a result of that anxiety require help in any activities that were performed outside the home. The claimants most often qualifying under part C are those with agoraphobia.

Continue to Residual Functional Capacity Assessment for Anxiety Disorders.

Can I Get Social Security Disability Benefits for Arthritis or Joint Damage?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits Due to Joint Problems?
• About Joint Pain and Joint Damage
• Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing
• Residual Functional Capacity Assessment for Joint Dysfunction
• Getting Your Doctor’s Medical Opinion About What You Can Still Do

How Does the Social Security Administration Decide if I Qualify for Disability Benefits Due to Joint Problems?

If you have joint pain or damage from any cause including arthritis, Social Security disability benefits may be available. To determine whether you are disabled by your joint condition, the Social Security Administration first considers whether your joint problems are severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Joint Pain and Joint Damage by Meeting a Listing.If you meet or equal a listing because of joint problems, you are considered disabled. If your arthritis or other joint condition is not severe enough to equal or meet a listing, Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your joint condition), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Joint Pain and Joint Damage.

About Joint Pain and Joint Damage

Impairments Causing Joint Pain or Joint Damage

Joint pain and loss of joint mobility may be caused by a number of disorders including:

• Osteoarthritis
• Rheumatoid arthritis
• Psoriatic arthritis
• Infectious arthritis and osteomyelitis
• Gout
• Systemic lupus erythematosis (SLE)
• Osteonecrosis
• Scleroderma
• Polymyositis
• Reiter’s Syndrome
• Traumatic damage to joints
• Neuropathic arthropathy

Osteoarthritis

In all joints, osteoarthritis is the most common arthritis seen by the Social Security Administration. Osteoarthritis is also known as hypertrophic arthritis or degenerative arthritis. Osteoarthritis is not a systemic disease. It doesn’t affect the entire body; its effects are confined to the involved joints. Osteoarthritis is slowly progressive and starts with damage to the cartilage on opposing ends of bone inside the joint space (see Figure 1 below). Any joint in the body can be involved. Heavy impact activity on joints predisposes to the development of osteoarthritis , and osteoarthritis is associated with advancing age. Trauma to a joint, such as a fracture into a joint space, is frequently followed by development of osteoarthritis.

Figure 1: Osteoarthritis joint abnormalities.

As joint cartilage begins to soften and thin, unusual stresses are also put on the underlying joint bone. The body responds to cartilage and bone damage by trying to grow new bone. This process can lead to osteophytes (spurs) around joints or in the spine, as well as narrowing of whatever joint space is involved.

Generally, claimants with osteoarthritis applying for disability benefits allege some degree of limiting symptoms (e.g., pain, and stiffness). Individual symptoms and function vary greatly, and disability determination should not be based on any one finding, such as X-ray evidence, alone. However, objective abnormalities like deformity, restriction in joint motion, and joint narrowing on X-ray play an important role in convincing the Social Security adjudicator that your report of your symptoms is credible.

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease in which the body’s own immune cells attack and damage the joints. The precise cause of rheumatoid arthritis is still not clear. Rheumatoid arthritis is seen 2 to 3 times as frequently in females as males. Rheumatoid arthritis often comes on gradually.

The primary target for rheumatoid arthritis is the synovial membrane that surrounds and protects joints (see Figure 2 below). The synovial membrane that surrounds the joints is damaged early in the disease. In more advanced cases the ligaments, tendons, and bone are affected. Rheumatoid arthritis can damage the bone by causing it to dissolve, a process known as erosion, which can be seen on X-ray. Erosion is more serious than inflammation alone. Erosions may be of any degree of severity.

Figure 2: The synovial membrane in an elbow joint.

Symmetry is a characteristic of rheumatoid arthritis, and means that the same joints are generally involved on both sides of the body at the same time, such as arthritis in both the right and left thumbs.

Rheumatoid arthritis is not always only an arthritic disease. It can sometimes result in:

• Lung disease such as fibrosis; see Can I Get Social Security Disability Benefits for Lung Disease
• Damage the heart muscle (cardiomyopathy)
• Inflammation of the membrane surrounding the heart (pericarditis)
• Damage to heart valves
• Anemia and
• Damage to peripheral nerves (neuropathy).

No claimant with rheumatoid arthritis should ever have his or her claim for disability benefits decided solely with a joint examination a general physical examination should always be documented.

Treatment of rheumatoid arthritis consists of adequate rest, protection of joints from stress, physical therapy, and drugs. Surgery is sometimes done to help correct joint deformities.

Drugs used to treat rheumatoid arthritis include non-steroidal, anti-inflammatory drugs (NSAIDS) such as aspirin or ibuprofen, steroids, gold, methotrexate, etanercept, and others as appropriate.

A wide range of toxic side-effects of medication can occur with various drugs given to treat rheumatoid arthritis and other inflammatory joint disorders. Long-term use of steroid drugs like prednisone can affect mood, as well as cause hypertension and contribute to obesity. The Social Security Administration should always ask the treating doctor about any drug toxicity before making a final determination.

Flare-ups may occur at unpredictable intervals despite treatment; the frequency, duration, and severity of these flare-ups are linked to the behavior of the disease in the individual person.

With the advent of new drugs and understanding in the past several decades, progression to deforming arthritis is much less common, and a significant percentage of rheumatoid arthritis patients can maintain normal function if treatment is started early in the onset of the disease.

Psoriatic Arthritis

Psoriatic arthritis is a form of arthritis associated with the skin disorder psoriasis. Some patients are unaware that their joint symptoms have anything to do with their skin disorders. The cause of psoriatic arthritis is unknown. Like rheumatoid arthritis, psoriatic arthritis can produce joint inflammation. But it occurs with equal incidence in both sexes. Psoriatic arthritis is more likely than rheumatoid arthritis to involve the hand joints nearest the fingertips (distal interphalangeal joints). It also may involve the mid-finger joints and the knuckle joints (see Figure 3 below).

Figure 3: Hand and finger joints.

In psoriatic arthritis, unlike RA, there is a tendency for involvement of joints on one side of the body (asymmetry) without involvement of the opposite side. For example, a person with psoriatic arthritis may have arthritis in the right thumb joints but not the left thumb joints.

The inflammation of psoriatic arthritis produces what is typically described as a “sausage-like” swelling of the fingers. In addition to possibly involving the hand and other peripheral joints (such as the elbow or knee), psoriatic arthritis can cause inflammatory damage to the spine and sacroiliac joints of the pelvis with associated back pain and stiffness. See Can I Get Social Security Disability Benefits for Back Pain?

There are no diagnostic tests for psoriatic arthritis. Increased uric acid levels may lead to a false diagnosis of gout.

X-ray evaluation is helpful in diagnosis. Psoriatic arthritis will tend to show asymmetric joint abnormalities, involvement of distal interphalangeal joints (DIP joints), inflammation of the sacroiliac joint (sacroiliitis), inflammation of the spine (spondylitis), ankylosis (fusion) of bone in involved joints, erosions of bone with formation of new bone, and resorption (dissolution) of bone in the distal phalanges of the hands (fingertip bones).

Most people with psoriatic arthritis have mild abnormalities, and less than 5% develop deforming arthritis. At least 25% of patients will develop bone destruction if only one joint is involved, but more than 60% will develop bone destruction with multiple (polyarticular) joint involvement. Bony damage can progress even if the soft-tissue inflammation is controlled. Severe finger deformities known as “arthritis mutilans” may be associated with psoriasis.

Treatment involves therapy for the skin lesions and to decrease joint inflammation. Ibuprofen may be sufficient for control in early cases of psoriatic arthritis, while psoralen with ultraviolet light (PUVA) may be used for severe skin inflammation. More severe cases may be treated with gold or immune suppressant drugs such as methotrexate or cyclosporine. If cyclosporine is used to treat psoriatic arthritis, consideration must be given to the risk of kidney toxicity (nephrotoxicity) and also the development of hypertension (high blood pressure). Gold therapy can suppress cell production in the bone marrow with resultant anemia. Anemia can result in easy fatigability and tiredness. Other blood abnormalities can also be caused by gold. For example, gold can decrease white cells needed to fight infection and decrease platelets needed to resist bleeding, it can be toxic to the kidneys and has other potential problems.

Psoriatic arthritis can affect the aortic heart valve, although this is a late finding occurring in a small minority of cases. Involvement of the spine, such as with Reiter’s syndrome, can result in pain and marked restriction in ability to bend the back. See Can I Get Social Security Disability Benefits for Back Pain?

Infectious Arthritis and Osteomyelitis

Infections of joints from bacteria such as gonorrhea will resolve with antibiotic treatment, so they usually do not satisfy the 12-month duration requirement for Social Security disability benefits. It is unusual for infectious arthritis (septic arthritis) to produce deformity severe enough to qualify under the joint dysfunction listing. See Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing. However, bone infection (osteomyelitis) in joints is a more serious matter.

Osteomyelitis most often occurs as a result of trauma that produces open wounds that allow bacteria into the body, surgical procedures, or bacteria circulating in the bloodstream—a condition known as bacteremia. Osteomyelitis of joints can affect their function by means of bone destruction and joint deformity.

In weight-bearing bones, fractures through the area of infection can occur during the stage of acute infection, or later due to brittle bone. The orthopedic surgical management of osteomyelitis can be complex. Surgery may be needed to remove infected bone. In rare cases, amputation (such as of a toe) may be necessary.

With modern antibiotics, acute osteomyelitis can be treated more effectively, so that chronic osteomyelitis is not as common as it was in the past. When chronic osteomyelitis does occur, it can present a difficult problem because the chronically infected bone may die and that restricts delivery of antibiotics through the bloodstream. Also, secondary infection may occur in tissues near the bone that involves different organisms than those that infect the bone itself.

An area of infected bone is called a sequestrum. In the treatment of chronic osteomyelitis, surgery to remove the sequestrum (sequestrectomy and curettage) along with infected soft tissues near the infection is a common requirement. Infected soft tissue removal may require reconstruction of soft tissues, such as muscle and skin grafts. The hole in the bone left by removal of the sequestrum may be packed with antibiotic beads. Antibiotic bead implantation may be temporary (10 days) to permanent, depending on the judgment of the surgeon. Whatever surgical antibiotic treatment is given, the patient will require prolonged systemic antibiotic therapy lasting well through surgical recovery, in order to prevent recurrent infection.

Infected bone fractures can be particularly difficult to heal. Such a situation might arise from an open wound and fractures occurring during an automobile accident or other trauma.

Gout

Gout is a metabolic disorder associated with increased blood uric acid and sometimes deposits of urate crystals in joints—gouty arthritis. The gout can be primary form, caused by a defect in purine metabolism, or it can be secondary related to drugs or other diseases. In either case, gouty arthritis can almost always be effectively treated. A swollen and painful joint treated with colchicine will usually return to normal in several days. However, gout can damage bone as well as produce acute inflammation. Typically, gout produces erosions of bone at the margins while leaving the joint space intact. Because of these considerations, it would be very unusual for gout to produce the kind of deformity and functional loss required by the listing for joint dysfunction. See Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing. Gout is predominantly a male disorder, and it is extremely rare for gout to occur in women under age 50.

Systemic Lupus Erythematosis (SLE)

Systemic lupus erythematosis is an incurable autoimmune disease, characterized by the production of antibodies against normal tissues and the formation of damaging immune complexes, as well as other immune system abnormalities such as T cell lymphocyte dysfunction. SLE occurs 9 to 10 times more often in women than men, especially young women still in their reproductive years. Virtually any body system can be involved and resulting impairments must be evaluated under the appropriate listing. See Can I Get Social Security Disability Benefits for Lupus?

Susceptibility to the development of SLE depends on multiple abnormal genes. Lupus can produce any degree of impairment. The Social Security Administration sees many lupus cases. To make an accurate disability determination, the Social Security Administration must have a thorough and complete physical examination of the claimant, including a careful examination of the joints. Although it is unusual for joint deformities to develop in SLE, there is a type of ulnar deviation deformity seen in some cases of SLE called Jaccoud’s arthritis. Unlike the ulnar deviation associated with rheumatoid arthritis, Jaccoud’s arthritis is reversible and does not cause severe deformity-associated functional limitations. A more serious complication affecting joints is osteonecrosis (see below).

Systemic Lupus Erythematosus and Osteonecrosis

Systemic lupus erythematosus (SLE) can result in the degenerative bone condition of osteonecrosis that can affect shoulder, hip, knee, and ankle joints. Osteonecrosis is a condition that occurs predominantly in women with SLE, and 90% of cases occur in association with the risk factors of alcohol and tobacco use, kidney disease, and the corticosteroid drugs sometimes used to treat the SLE. Osteonecrosis is not rare in SLE—the incidence is reported to be somewhere between about 3% to 40% in various studies. This wide range of values may be related to differences in the types of patients seen and the type of imaging studies used. For example, MRI is more likely to show early osteonecrosis changes than are plain X-rays. MRI has about a 99% sensitivity for detecting osteonecrosis.

Studies indicate that osteonecrosis damage to bone can start within several months of beginning corticosteroid therapy. Joint deformity can lead to the need for prosthetic joint replacement. Symptoms can appear before there are detectable X-ray changes. Osteonecrosis is suggested by the gradual onset of a deep, throbbing pain localized to bone that may be near a joint rather than in it. It is easy for the serious disorder of osteonecrosis of the hip to be misdiagnosed as a much less serious trochanteric bursitis if there is pain in the hip area. Additional confusion in diagnosis can result from the fact that osteonecrosis of the hip can project pain so that it is felt in the groin. Since osteonecrosis can produce significant symptoms prior to imaging studies showing any significant abnormality, the Social Security Administration adjudicator may fail to realize the possibility of osteonecrosis.

Scleroderma

Scleroderma means a hardening (sclero-) of the skin (-derma), and is caused by a connective tissue disease of unclear origin. Examples of connective tissue are skin, ligaments, bone, muscle, and tendons (see Figure 4 below). Scleroderma is sometimes used synonymously with progressive systemic sclerosis (PSS), which is actually the systemic form of the disease that can affect a variety of organ systems in addition to skin—gastrointestinal, heart, muscles, kidneys, and lungs.

Figure 4: Connective tissues in the knee.

There is no single diagnostic test for scleroderma, although auto-antibody testing and biopsy, along with physical examination, can provide important information. Scleroderma is variable in severity and progression, but incurable, and there is no effective way to arrest worsening. When joints are involved, there may be a non-painful swelling in the fingers, but it is also possible to have joint pain (arthralgia) and stiffness in joints that could qualify under the listing for joint dysfunction. See Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing. In unusual cases, scleroderma can produce deforming arthritis mutilans. See Psoriatic Arthritis.

Polymyositis

Polymyositis is an autoimmune disorder involving connective tissue inflammation, especially muscle tissue. It can potentially affect multiple major organ systems. The disorder can be present in “overlap” syndromes that have characteristics of both scleroderma and polymyositis. Polymyositis can produce inflammation that can qualify under the listing for joint dysfunction. See Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing. It can also produce joint deformity; such deformity is most often in the distal finger joints (joints near the fingertips).

Reiter’s Syndrome

Classic Reiter’s syndrome consists of urethritis (inflammation of the urethra), arthritis, and conjunctivitis. By these strict criteria, it is a rare disorder. However, if involvement of the spine and sacroiliac joints of the pelvis (spondyloarthropathy) is included, Reiter’s syndrome is a more prevalent disease.

The knees, ankles, and feet are the most commonly involved joints. Symptoms in these joints tend to occur early in the course of the disease along with joint stiffness. Involvement of the ankle and heel can be particularly debilitating. The inflammatory response usually doesn’t produce gross swelling in joints (except for the knee), but the persistent presence of any inflammatory swelling along with tenderness, pain, and limitation of function can satisfy the listing. See Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing. If the fingers are involved in the arthritic process, the swelling may involve the entire finger to cause it to appear sausage-like, in contrast to rheumatoid arthritic swelling that tends to confine itself to the finger joint areas. Reiter’s syndrome can also affect other body systems such as the heart, but this usually occurs only as a late abnormality in about 10% of cases after the disease has been present for some years.

Reiter’s syndrome is thought to be an immune system disorder involving abnormal activity of T lymphocytes, though in some instances it might be triggered by an infection. Reiter’s syndrome is treated with non-steroidal anti-inflammatory drugs (NSAIDS) such as aspirin and ibuprofen. More potent drugs are reserved for cases that do not respond to milder medications. Factors associated with a poor prognosis include poor response to NSAIDS, onset before age 16, involvement of hip joints, elevated erythrocyte sedimentation rate (ESR) to greater than 30 mm/hr, swollen fingers or toes, and low back (lumbar) pain with limitation of motion. There is no cure but symptom severity may vary over time.

Traumatic Damage to Joints

Claims for Social Security disability benefits based on traumatic joint damage caused by automobile, motorcycle, or work-related accidents are common. Fractures into joint spaces have a high potential for producing post-traumatic arthritis and, perhaps, deformity. The more fragmented the joint-space bones, the more difficult it will be to return the joint to normal functional status. Additionally, ligaments that hold a joint in proper position (see Figures 5 and 6 below) can be partially or completely torn. Torn ligaments can destabilize a joint. For example, important ligaments stabilizing the knee joint are the anterior and posterior cruciate ligaments. Some claimants have unstable joints resulting from damage to these structures.

Figure 5: Ankle ligaments.

Figure 6: Knee ligaments.

Neuropathic Arthropathy

Neuropathic arthropathy is joint damage caused by failure of sensation, particularly pain, to offer its protective effect for joints. Consequently, the individual experiences joint damage without realizing it is being done. Numerous disorders can cause decreased joint sensation that leads to joint damage and deformity. Some examples include diabetes mellitus, central nervous system disorders (e.g., syringomyelia, meningomyelocele, spina bifida, brain injury, paraplegia), post-kidney transplant cases, multiple sclerosis, arthritis mutilans, scleroderma, nervous system infections, and various hereditary diseases. See Can I Get Social Security Disability Benefits for Diabetes? and Can I Get Social Security Disability Benefits for Multiple Sclerosis?

Continue to Winning Social Security Disability Benefits for Joint Dysfunction by Meeting a Listing.

Can I Get Social Security Disability Benefits for Asthma?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Asthma?
• About Asthma and Disability
• Winning Social Security Disability Benefits for Asthma by Meeting a Listing

How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Asthma?

If you have asthma, Social Security disability benefits may be available. To determine whether you are disabled by asthma, the Social Security Administration first considers whether your asthma is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Asthma by Meeting a Listing. If you meet or equal a listing because of asthma, you are considered disabled. If your asthma is not severe enough to equal or meet a listing, Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your asthma), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Asthma.

About Asthma and Disability

What Is Asthma?

Asthma is a type of chronic obstructive lung disease (COPD). It is a chronic inflammatory disease of the breathing or bronchial tubes

see Figure 1 below

. Muscles in the bronchial tubes constrict due to irritation, which can be an innate problem or can be caused by inhaling certain substances. In addition to constriction, inflammation causes swelling and excess mucus that further narrows the bronchial tubes. The combination of constricting muscles and inflammation obstructs the flow of air in the lungs. Asthmatic attacks can cause shortness of breath, chest tightness, wheezing, and coughing.

Asthma can also be called asthmatic bronchitis, chronic asthmatic bronchitis, or reactive airways disease. Asthma frequently begins in childhood or adolescence, but can occur at any time in adult life.

Figure 1: Diagram of the bronchial tubes and lungs.

Severity of Asthma Attacks

Asthma attacks can be mild and infrequent, responding to an inhaled bronchodilator. They can also be frequent and severe enough to be life-threatening. A diagnosis of asthma alone does not mean you are entitled to Social Security disability benefits. When properly treated, people with asthma have participated in the Olympics, professional sports, amateur sports, and school-related sports without danger or difficulty.

Treatment for Asthma

For years researchers have studied genetic, environmental, and immunological factors that may play a role in asthma. Despite gaps in knowledge, they have made considerable progress in treatment. Both the inflammation and the bronchial narrowing must be controlled for effective treatment. Patients with chronic asthma who receive inhaled steroids to reduce inflammation along with bronchodilators to relax tight muscles do better than those who receive bronchodilators alone. Many asthma patients do not receive the proper type or optimum dose of medications. Also, some asthma patients continue to smoke cigarettes, and others cannot or will not follow prescribed therapy.

Asthma Attack Triggers

Asthma is worsened by the air pollution common in larger cities. Intense emotion, cold air, dusts, pollens, and other types of air particulates can bring on an attack. Asthma attacks can be related to exposure to various pollutant or industrial gases, particularly sulfur dioxide (SO2) and nitric oxide (NO2). Respiratory viral infections can make bronchial inflammation worse and can precipitate asthmatic attacks. Allergic rhinitis (“hay fever”) and sinusitis are associated with worse asthmatic symptoms. Some medications tend to increase bronchial mucous secretion and bronchial constriction and can worsen symptoms. Heartburn can worsen bronchial irritation if stomach acid is inhaled into the airway. So multiple medical and environmental factors must be evaluated and controlled for the best therapeutic results. See Asthma Triggers in the Workplace.

Related Conditions

Individuals with asthma can also have other types of obstructive or restrictive lung disease, which can complicate diagnosis, treatment, and the Social Security disability determination. Smokers with emphysema and chronic bronchitis have inflammation of their airways that results in broncho-constriction, although they would not be considered to have true asthma. They may be treated with bronchodilator drugs, such as theophylline, if the constriction is reversible. But be aware that the Social Security Administration will not assume that you have a particular condition just because you take a particular medication.

Winning Social Security Disability Benefits for Asthma 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 asthma is severe enough to meet or equal the asthma 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 the Social Security Administration presumes would prevent a person from performing substantial work. If your asthma is severe enough to meet or equal the asthma listing, you will be considered disabled.

The listing for asthma is 3.03, which has two parts: A and B. You will be eligible for Social Security disability benefits if you meet either part.

Meeting Social Security Administration Listing 3.03A for Asthma

According to this listing, if you are diagnosed with chronic asthmatic bronchitis, you will be evaluated under the criteria for chronic obstructive pulmonary disease in listing 3.02A (Chronic Pulmonary Insufficiency), which provides that a claimant is disabled if he or she has:

Chronic obstructive pulmonary disease due to any cause, with the FEV1 equal to or less than the values specified in Table I corresponding to the person’s height without shoes.

FEV1 is measured by a spirometer. The device measures the volume of air that you can inhale and exhale and displays the result on a graph called a spirogram. Spirometry is the most important test for evaluating obstructive lung disease. FEV1, which stands for forced expiratory volume in one second, decreases in proportion to the severity of the lung disease. In other words, the lower your FEV1, the more severe your lung disease is.

Meeting Social Security Administration Listing 3.03B for Asthma

A Social Security disability claimant with asthma meets listing 3.03(B) and is disabled if he or she has:

Attacks in spite of prescribed treatment and requiring physician intervention, occurring at least once every 2 months or at least six times a year. Each in-patient hospitalization for longer than 24 hours for control of asthma counts as two attacks, and an evaluation period of at least 12 consecutive months must be used to determine the frequency of attacks.

Attacks of asthma are defined as:

Prolonged symptomatic episodes lasting one or more days and requiring intensive treatment, such as intravenous bronchodilator or antibiotic administration or prolonged inhalational bronchodilator therapy in a hospital, emergency room or equivalent setting.

Therefore, not every asthma attack counts. To meet Listing 3.03B, you must have attacks that require a trip to the ER or treatment by a doctor to control. Attacks that you can control yourself with your inhaler or home nebulizer do not count.

Documentation of your medical treatment is the key to winning a disability claim under listing 3.03B. Note the phrase “in spite of prescribed treatment…” If you don’t have a medical history, you cannot possibly qualify under part B since you cannot satisfy the requirement of being under the care of a physician.

Continue to Residual Functional Capacity Assessment for Asthma.

Can I Get Social Security Disability Benefits for Back Pain and Spine Immobility?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Back Pain or Spine Impairments?
• About Back Pain and Disability
• Winning Social Security Disability Benefits for Back Problems by Meeting a Listing
• Residual Functional Capacity Assessment for Back Pain
• Getting Your Doctor’s Medical Opinion About What You Can Still Do

How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Back Pain or Spine Impairments?

If you have a spine disorder that limits movement or causes chronic back pain, Social Security disability benefits may be available. To determine whether you are disabled by your back pain, or other spinal problems, the Social Security Administration first considers whether your back problems are severe enough to meet or equal a listing at Step 3 of theSequential Evaluation Process. See Winning Social Security Disability Benefits for Back Pain by Meeting a Listing. If you meet or equal a listing because of back pain or other spine disorders, you are considered disabled. If your back problems are not severe enough to equal or meet a listing, Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your back), to determine whether you qualify for benefits at Step 4 and Step 5of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Back Pain and Spine Impairments.

About Back Pain and Disability

Impairments Causing Back Pain and Spine Immobility

Allegations of disability based on “back pain” are extremely common. Back pain and movement problems may be caused by a number of disorders including:

• Osteoarthritis (OA)
• Degenerative disc disease (DDD)
• Herniated nucleus pulposus (HNP) or herniated disc
• Osteoporosis
• Trauma
• Tumor
• Arachnoiditis
• Lumbar strain
• Spondylolisthesis
• Spinal stenosis

<liScoliosis

• Kyphosis
• Osteomyelitis

 

Some people may have structural problems in the spine that limit function (i.e., walking, bending, stooping, etc.). But question of disability usually depends on how much your chronic pain interferes with your ability to function (i.e., walk, bend, stoop, twist, lift, etc.). The great majority of individuals—more than 80%—who have acute low back pain from a strain of the ligaments and other soft-tissue supportive structures of the spine will recover within several months, even if they receive no treatment. Other individuals have a more chronic problem.

Spine Anatomy

The spine (vertebral column) has:

• 7 cervical (neck) vertebrae.
• 12 thoracic (chest, dorsal) vertebrae.
• 5 lumbar (lower back) vertebrae.
• 5 sacral vertebrae (fused triangular bone).
• 3 or 4 little vertebrae fused into a coccyx at the lower end of the spinal column.

Figure 1: The human spine.

The spine provides structural support for the body and protects the spinal cord. Thirty-one pairs of nerve roots exit the spinal cord to form the peripheral nerves to the rest of the body. The peripheral nerves are sensory (carrying sensation), and motor (causing muscle movement). Disease processes affecting the spine can damage peripheral nerves at or near their origin (nerve roots), as well as the spinal cord itself.

Assessing Back Pain

The severity of back pain cannot be deduced solely based on abnormalities that are seen on plain X-rays, computerized tomography (CT), or magnetic resonance imaging (MRI) of the spine. Many people with significant degenerative abnormalities on X-ray have minimal or no symptoms, while some people who allege incapacitating back pain have minimal objective abnormalities. Nevertheless, even taking individual differences into account, there is a general correlation between objective abnormalities and credible pain.

The Social Security Administration will weigh your objective abnormalities, your reported pain and other symptoms, and your credibility in determining the severity of your impairment. In addition to objective evidence, your credibility with the Social Security Administration is strongly influenced by your behavior in seeking relief of alleged symptoms, your activities that are limited by pain, the nature and frequency of your visits to a doctor for treatment, your response to treatment given, and comments about your credibility in the treating doctor’s records.

Psychological and Social Factors in Back Pain

Although psychosocial factors play a major role in the functional loss caused by low back pain, there is no good way for the Social Security Administration to evaluate these factors. Psychosocial factors strongly predict future disability and the use of health care services for low back pain. Chronic disabling low back pain develops more frequently in patients who, at the initial evaluation for low back pain, have:

• A high level of “fear avoidance” (an exaggerated fear of pain leading to avoidance of beneficial activities);
• Psychological distress;
• Disputed compensation claims;
• Involvement in a tort-compensation system; or
• Job dissatisfaction.

These psychosocial factors are particularly prevalent in persons with low back pain for whom imaging shows only degenerative changes; 70 to 80 percent of such patients demonstrate psychological distress on psychometric testing or have disputed compensation issues, compared with 20 to 30 percent of patients whose imaging studies reveal definite pathologic or destructive processes. These psychosocial factors should be routinely assessed in patients with low back pain and taken into account in decisions regarding treatment.

Osteoarthritis (OA)

Some degree of osteoarthritis of the spine is common in middle-aged people, even if they are not aware of it. OA of the spine can take several forms. In ankylosis, parts of the spine are abnormally fused together as a result of bony overgrowth. For example, bony spurs can fuse vertebral bodies together. The peripheral nerves formed from the spinal cord exit the bony spine through recesses in vertebrae called intervertebral foramina (see Figure 2 below). Some of these foramina can become encroached by osteoarthritis and require surgical decompression. Vertebrae have contact points with other vertebra called facet joints (see Figure 3 below.Arthritis affecting these facet joints can be painful and limit the motion of the spine. See also Can I Get Social Security Disability Benefits for Arthritis and Joint Damage?

Figure 2: Spinal cord and nerve roots.

Figure 3: Normal spinal canal with facet joints.

Degenerative Disc Disease (DDD)

Degenerative disc disease refers to dehydration and shrinkage of the intervertebral discs that cushion the vertebral bodies of the spine. DDD is common and causes no symptoms in many older individuals. Everyone over about the age of 50 has some degree of DDD, which may or may not be symptomatic and functionally limiting. Osteoarthritis of the spine is frequently accompanied by DDD, while DDD without associated OA is also common. DDD can be seen on X-rays, MRI, and CT scans of the spine. It appears as narrowing of the space between vertebral bodies. Symptomatic DDD occurs between the 5th lumbar vertebra and the 1st sacral vertebra (L5-S1).

Sometimes a combination of OA and DDD produces enough symptoms that surgical fusion is performed in the lumbar spine (lumbar fusion) or cervical spine (neck). This procedure is done in an attempt to stabilize the spine and decrease pain. The surgery requires taking strips of bone from the posterior (back) upper part of the pelvic bone and laying them over the vertebral bodies that need to be stabilized (see Figure 4 below. Bone is living tissue and will incorporate the vertebral bodies into one solid mass. Sometimes, the bone strips do not incorporate well and the surgical fusion partially or wholly fails. Some fusions involve only two vertebrae, but multiple vertebrae may also be fused.

Figure 4: Vertebral fusion using bone strips.

Herniated Nucleus Pulposus (HNP) or Herniated Disc

A herniated nucleus pulposus is the protrusion of the hard, cartilaginous center (nucleus) of an intervertebral disk through the outer fibrous tissue (annulus fibrosa) (see Figures 5 and 6 below). Many small HNPs will produce acute symptoms that improve with time. Injection of corticosteroid drugs in the area of the HNP can also help relieve inflammation and pain. Some claimants have a large HNP that presses on a spinal nerve root, and must have part of the HNP removed (discectomy, diskectomy).

Figure 5: An intervertebral disk with lateral herniation.

Figure 6: MRI view of herniated discs.

Often, a part of a vertebral body, the lamina, is also removed for surgical access and this procedure is known as a laminectomy. The problem with surgery around spinal nerve roots is that manipulation of tissues often leads to scarring that then again pressures the nerve root. This is particularly likely when a person has had multiple back surgeries. Many claimants who complain of chronic back pain and have a history of back surgery near nerve roots have scarring that can be identified on CT or MRI scans. In the absence of trauma, most HNPs occur in the lumbar (lower) spine, especially at the level of L5-S1.

Osteoporosis

Osteoporosis is a metabolic disorder associated with decrease in the mass of bone. By far, most of the instances of osteoporosis seen by the Social Security Administration are in post-menopausal women. Osteoporosis may be confined to the spine, but other bones may be involved in those who have used corticosteroids. A collapse of vertebral bodies, especially in the upper back, is known as a compression fracture. Compression fractures are visible on plain X-ray or other imaging studies. If the fracture involves the anterior (front) part of a vertebral body more than the rest of the vertebra, the spine will tend to curve forward and result in the popularly known dowager’s hump.

Compression fractures are graded in regard to the percent of the vertebra that is compressed, compared to the normal height of the vertebra. Normal height is judged from adjacent vertebrae. Pain, loss of motion, and muscle spasm are most likely to be present at the time of fracture and in the healing period. Marked or multiple compression fractures are more likely to produce chronic pain.

Plain X-rays are much less sensitive than bone densitometry in determining the severity of osteoporosis. A normal appearance of bone on plain X-rays only rules out the most advanced osteoporosis. Plain X-rays are fine for determining the percentage of vertebral body collapse in compression fractures.

Trauma

Fractures of the bony spine are most commonly related to automobile or motorcycle accidents. There may be associated spinal cord injury. Traumatically fractured vertebrae are treated with a combination of surgical fusion and sometimes stabilization with metal rods.

Tumor

The most serious tumors of the spine arise from cancer that has spread to the spine from breast, colon, prostate, or other origin. Tumors can not only cause chronic pain, but result in spinal fractures as they destroy bone. The spread of cancer of any kind to the spine is a serious development that must also be considered under the listings dealing with cancer.

Arachnoiditis

Arachnoiditis is inflammation of some part of the arachnoid membrane that covers the spinal cord. It can produce severe chronic pain. Arachnoiditis may occur as a result of infection, but most commonly is seen after surgical procedures and use of contrast material to enhance visualization of structures with X-rays during myelography. Some people are more sensitive than others to contrast material. An MRI scan has about a 90% chance of showing this abnormality if it is present. A negative MRI scan for arachnoiditis is a strong argument that it is not present.

Lumbar Strain

Lumbar strain refers to stress on the ligaments, muscles, and other soft tissues near the spine with resultant pain. There may or may not be underlying arthritis or DDD. Acute strain, associated with a particular lifting event, will almost always resolve in several months. If the pain is marked, there is associated muscle spasm and difficulty bending the back. When back pain continues for a prolonged period, orthopedists and other doctors tend to apply the diagnosis of “chronic lumbar strain,” if there is no other underlying identifiable abnormality that can be seen on imaging studies.

Spondylolisthesis

Spondylolisthesis is a slippage of vertebral bodies out of their normal position, usually a forward slippage of the 5th lumbar vertebra over the 1st sacral vertebra (L5-S1). More rarely, a type of spondylolisthesis called retrolisthesis involving the backward displacement of a vertebral body occurs. Most spondylolisthesis is seen in the lumbar spine (L1-L5/S1). This disorder can been seen on plain X-rays. It is significantly more likely to be seen on X-rays taken in the standing position than in those taken in lying position—with weight on the spine, slippage is more likely.

However, severe or even significant neurological abnormalities (sensory changes, reflex changes, muscle weakness or atrophy) are not to be expected in spondylolisthesis.

Studies have shown that most individuals with spondylolisthesis, lead active lives with little, if any, adjustment for having this type of spinal abnormality. Spondylolisthesis is most likely to become limiting as a contributing factor for spinal stenosis in combination with other spinal disorders, such as severe osteoarthritis and severely bulging intervertebral discs.

Spinal Stenosis

Spinal stenosis is a narrowing of the space inside the bony spine (see Figure 7 below), which sometimes results in pressure on the spinal cord and peripheral nerve roots from the spinal cord. The Social Security Administration most commonly sees such cases in claimants who have severe osteoarthritis of the lower spine. Spinal stenosis can be worsened by bulging or herniated disks (HNPs) (see Figure 8 below) and spondylolisthesis.

Figure 7: Spinal stenosis with a narrowing of the spinal canal.

Figure 8: Spinal stenosis caused by a herniated disk and osteoarthritis.

Spinal stenosis most commonly involves the lower back, specifically the area somewhere between the 3rd lumbar vertebra and the beginning of the sacrum (L3-4, L4-5, and L5-S1 levels). Less frequently, the neck (cervical spine) may be involved with spinal stenosis; its presence in the upper back (thoracic spine) is rare.

Spinal stenosis is one of many possible causes of damage to the spinal cord (myelopathy). Myelopathy may be irreversible. Surgical decompression of the spinal cord may be necessary for severe cases, but even after surgery symptoms may not improve.

Pain and neurological abnormalities can be debilitating if treatment is not effective. Standing, walking, lifting, and carrying should be limited to weight that does not produce symptoms. A person with lumbar stenosis may have no symptoms during a physical examination, but may have severe symptoms with exertion.

Pain, weakness, numbness or other symptoms related to spinal stenosis usually appear gradually over a period of months or years. Symptoms are rapidly worsened by walking, lifting, jarring, carrying or other activities that strain the spinal structures. Sensory abnormalities, such as numbness, will occur before the onset of weakness. Symptoms are lessened or relieved by bending forward (including crouching) or lying. These symptoms are referred to as pseudoclaudication by the Social Security Administration, but are often also called neurogenic claudication.

In addition to osteoarthritis, causes of spinal stenosis include congenital spinal deformities (scoliosis,kyphosis, or congenital skeletal dysplasias like achondroplastic dwarfism); acquired deformities such as post-traumatic spinal fractures; inflammatory spinal diseases like ankylosing spondylitis; or stenosis may be of unknown cause. Tumors or infection present possible reversible causes of lumbar stenosis.

Spinal stenosis can be seen on imaging studies such as myelography, CT, and MRI scans. But myelography and CT scans can miss some types of stenosis.

Scoliosis

Scoliosis is a sideways curvature to the spine (see Figure 9 below), associated with pain but not neurological impairment. Scoliosis can be of any degree of severity. Often the scoliosis is associated with one leg being shorter than the other. In these instances, the pelvis is not level causing the abnormal sideways spinal curvature. Scoliosis should be suspected with leg length discrepancies of 2.2 cm or greater.

Figure 9: Varying degrees and types of scoliosis.

The abnormal spinal curve of scoliosis is measured on plain X-rays. The measurement is called a Cobb angle. Scoliosis may be considered present with abnormal curves greater than 10 degrees. Mild cases have angles less than 30 degrees.

Angles of 20 degrees or less are usually produce no symptoms. Bracing is prescribed for angles over 20 degrees. Curves over 40 degrees may produce neurological abnormalities such as sensory loss and weakness. Small curves of less than 30 degrees in childhood are not likely to get worse during adulthood, while more severe curves may continue to progress. Surgery with permanent rod implantation and fusion is indicated with curves greater than 45 degrees.

Claimants with curves 60 degrees or more require spirometry for restrictive lung disease (decreased vital capacity). See Can I Get Social Security Disability Benefits for Lung Disease?Heart failure may occur from scoliosis when abnormal curves are markedly severe at 100 degrees or more. Such cases are very rarely seen in Social Security disability adjudication.

During physical examination, a doctor may use a device known as a scoliometer(scoliosometer)to measure the degree of curvature. The scoliometer measurement should not be confused with the spinal curvature, although both are expressed in degrees. A scoliometer reading of 7 degrees corresponds to a 20-degree curve measured by Cobb angle on X-ray. Scoliometers are inexpensive and useful for screening, but direct curve measurements on plain X-ray views are needed for accurate determinations.

Kyphosis

Kyphosis is an abnormal degree of curvature of the thoracic spine (upper back) in the forward direction (flexion). Kyphosis may be congenital or may occur in post-menopausal osteoporosis with collapse of the anterior (front) part of vertebral bodies in the upper back.

In kyphosis, forward curvature of the spine up to 20 degrees is considered normal, and mild up to 40 degrees. Bracing is prescribed for angles over 40 degrees and balance can be impaired by kyphotic curves greater than 40 degrees. Curves of 50 degrees or greater can produce a significant restrictive breathing deficit and should have vital capacity tested with spirometry. See Can I Get Social Security Disability Benefits for Lung Disease? As with scoliosis, extremely abnormal curves of 100 – 110 degrees or more can compromise cardiac function.

Osteomyelitis

Osteomyelitis most often occurs as a result of trauma producing open wounds that allows the entry of bacteria into the body, as a result of surgical procedures, or as a result of bacteria circulating in the bloodstream—a condition known as bacteremia. Osteomyelitis of joints can affect their function by means of bone destruction and joint deformity. See Can I Get Social Security Disability Benefits for Arthritis or Joint Damage?

In weight-bearing bones, fractures through the area of infection can occur during the stage of acute infection, or later due to brittle bone. The orthopedic surgical management of osteomyelitis can be complex. Surgery may be needed to remove infected bone.

With modern antibiotics, acute osteomyelitis can be treated more effectively, so that chronic osteomyelitis is not as common as it was in the past. When chronic osteomyelitis does occur, it can present a difficult problem because the chronically infected bone may die and that restricts delivery of antibiotics through the bloodstream. Also, secondary infection may occur in tissues near the bone that involves different organisms than those that infect the bone itself.

An area of infected bone is called a sequestrum. In the treatment of chronic osteomyelitis, surgery to remove the sequestrum (sequestrectomy and curettage) along with infected soft tissues near the infection is a common requirement. Infected soft tissue removal may require reconstruction of soft tissues, such as muscle and skin grafts. The hole in the bone left by removal of the sequestrum may be packed with antibiotic beads. Antibiotic bead implantation may be temporary (10 days) to permanent, depending on the judgment of the surgeon. Whatever surgical antibiotic treatment is given, the patient will require prolonged systemic antibiotic therapy lasting well through surgical recovery, in order to prevent recurrent infection.

Infected bone fractures can be particularly difficult to heal. Such a situation might arise from an open wound and fractures occurring during an automobile accident or other trauma.

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