Can I Get Social Security Disability Benefits for Reflex Sympathetic Dystrophy Syndrome / Complex Regional Pain Syndrome?

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

How Does the Social Security Administration Decide if I Qualify for Disability Benefits for RSDS / CRPS?

If you have reflex sympathetic dystrophy syndrome, Social Security disability benefits may be available to you. To determine whether you are disabled by your reflex sympathetic dystrophy syndrome (also called complex regional pain syndrome), the Social Security Administration will consider whether your condition qualifies as a severe medically determinable impairment at Step 2 of the Sequential Evaluation Process. See RSDS / CRPS as a Medically Determinable Severe Impairment. If your reflex sympathetic dystrophy/complex regional pain syndrome qualifies at Step 2, the Social Security Administration next considers whether your condition is severe enough to equal a listing atStep 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for RSDS / CRPS by Meeting a Listing.

If your reflex sympathetic dystrophy/complex regional pain syndrome is not severe enough to equal a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your 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 RSDS / CRPS.

About RSDS / CRPS and Disability

RSDS stands for reflex sympathetic dystrophy syndrome. CRPS stands for complex regional pain syndrome. RSDS and CRPS are two names for the same condition. RSDS / CRPS is a chronic, progressive neurological syndrome, characterized by severe pain, swelling, and changes in the skin.

The National Institute of Neurological Disorders and Stroke (NINDS) has defined RSDS as “a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems.”

RSDS usually affects one of the extremities (arms, legs, hands, or feet). The primary symptom is intense, continuous pain. Other symptoms include:

• Increased skin sensitivity.
• Skin temperature changes (warmer or cooler than opposing extremity).
• Skin color changes (blotchy, purple, pale, red).
• Skin texture changes (shiny, thin, sweaty).
• Changes in nail and hair growth patterns.
• Stiffness and swelling in affected joints.
• Decreased ability to move affected extremity.

The cause of RSDS/CPRS is unknown. Sometimes the syndrome is precipitated by injury and surgery, but some cases have no demonstrable injury to the original site.

RSDS / CRPS as a Medically Determinable Severe Impairment

You must have a medically determinable impairment that is severe to satisfy Step 2 of the Sequential Evaluation Process. The Social Security Administration has issued a ruling that focuses on proof that RSDS / CRPS is a medically determinable impairment. Below are some pertinent excerpts from that ruling.

Description of RSDS / CRPS

RSDS / CRPS is a chronic pain syndrome most often resulting from trauma to a single extremity. It can also result from diseases, surgery, or injury affecting other parts of the body. Even a minor injury can trigger RSDS / CRPS. The most common acute clinical manifestations include complaints of intense pain and findings indicative of autonomic dysfunction at the site of the precipitating trauma. Later, spontaneously occurring pain may be associated with abnormalities in the affected region involving the skin, subcutaneous tissue, and bone. It is characteristic of this syndrome that the degree of pain reported is out of proportion to the severity of the injury sustained by the individual. When left untreated, the signs and symptoms of the disorder may worsen over time.

Although the pathogenesis of this disorder (the precipitating mechanism(s) of the signs and symptoms characteristic of RSDS / CRPS) has not been defined, dysfunction of the sympathetic nervous system has been strongly implicated.

The sympathetic nervous system regulates the body’s involuntary physiological responses to stressful stimuli. Sympathetic stimulation results in physiological changes that prepare the body to respond to a stressful stimulus by “fight or flight.” The so-called “fight or flight” response is characterized by constriction of peripheral vasculature (blood vessels supplying skin), increase in heart rate and sweating, dilatation of bronchial tubes, dilatation of pupils, increase in level of alertness, and constriction of sphincter musculature.

Abnormal sympathetic nervous system function may produce inappropriate or exaggerated neural signals that may be misinterpreted as pain. In addition, abnormal sympathetic stimulation may produce changes in blood vessels, skin, musculature and bone. Early recognition of the syndrome and prompt treatment, ideally within 3 months of the first symptoms, provides the greatest opportunity for effective recovery.

How Is RSDS / CRPS Identified as a Medically Determinable Impairment?

For purposes of Social Security disability evaluation, RSDS/CRPS can be established in the presence of persistent complaints of pain that are typically out of proportion to the severity of any documented precipitant and one or more of the following clinically documented signs in the affected region at any time following the documented precipitant:

Swelling;

Autonomic instability–seen as changes in skin color or texture, changes in sweating (decreased or excessive sweating), changes in skin temperature, and abnormal pilomotor erection (gooseflesh);

Abnormal hair or nail growth (growth can be either too slow or too fast);

Osteoporosis; or

Involuntary movements of the affected region of the initial injury.

When longitudinal treatment records document persistent limiting pain in an area where one or more of these abnormal signs has been documented at some point in time since the date of the precipitating injury, disability adjudicators can reliably determine that RSDS / CRPS is present and constitutes a medically determinable impairment.

It may be noted in the treatment records that these signs are not present continuously, or the signs may be present at one examination and not appear at another. Transient findings are characteristic of RSDS / CRPS, and do not affect a finding that a medically determinable impairment is present.

Winning Social Security Disability Benefits for RSDS / CRPS by Equaling a Listing

To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration considers whether your impairment is severe enough to meet or a 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 the Social Security Administration presumes would prevent a person from performing substantial work. If your impairment is severe enough to meet or equal a listing, you will be considered disabled.

The Social Security Administration has no listing for RSDS / CRPS. Since RSDS / CRPS is not a listed impairment, you cannot be found to meet a listed impairment based on your RSDS/ CRPS alone. However, the specific findings in your case should be compared to any pertinent listing to determine whether “medical equivalence” may exist. In other words, you may be entitled to Social Security disability benefits if the severity of your condition equals an existing listing for a different impairment.

If you have psychological problems related to RSDS / CRPS, they should be evaluated under the mental disorders listings. The Social Security Administration should consider whether your impairments meet or equal the severity of a mental listing. See Can I Get Social Security Disability Benefits for Depression, Bipolar Disorder, or Mania? and Can I Get Social Security Disability Benefits for Anxiety, Phobias, Panic Attacks, Obsessive Compulsive Disorder, or PTSD?

Continue to Residual Functional Capacity Assessment for Complex Regional Pain Syndrome.

Can I Get Social Security Disability Benefits for Congestive (Chronic) Heart Failure?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Congestive Heart Failure?
• About Congestive Heart Failure and Disability
• Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing
• Residual Functional Capacity Assessment for Congestive Heart Failure
• 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 Congestive Heart Failure?

If you have congestive heart failure, Social Security disability benefits may be available. Congestive heart failure (CHF) is called chronic heart failure by the Social Security Administration. To determine whether you are disabled by CHF, the Social Security Administration first considers whether your heart failure is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing. If you meet or equal a listing because of CHF, you are considered disabled.

If your chronic heart failure is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your heart disease), to determine whether you qualify for disability benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Congestive Heart Failure.

About Congestive Heart Failure and Disability

The Cardiovascular System

Before discussing heart failure, a brief description of the cardiovascular system is needed. The heart is normally a four-chambered muscle situated behind and to the left of the sternum (breast bone). The upper chambers are the left atrium and right atrium. The lower chambers are the left and right ventricles. The ventricles are much larger than the atria (see Figure 1 below).

Figure 1: An anterior view of the heart, featuring the atria, ventricles, and arteries.

Oxygen depleted blood from the veins returns to the heart from the body’s tissues. It enters the right atrium and flows through the tricuspid valve into the right ventricle. The right ventricle pumps blood through the pulmonary valve and into the pulmonary arteries for re-oxygenation by the lungs.

Oxygenated blood from the lungs returns to the left atrium of the heart by pulmonary veins and passes through the mitral valve into the left ventricle. From the left ventricle, newly oxygenated blood is ejected through the aortic valve into the aorta, which is the parent artery of all of the body’s other arteries (see Figure 2 below).

Figure 2: The heart during contraction.

The arterial system of the body that receives blood pumped out of the left ventricle is known as the systemic circulation. The blood moving from the right ventricle through the lungs is called the pulmonary circulation. The valves are important because they open only in one direction, so that blood flow always moves the right way when the heart contracts.

What Is Congestive (Chronic) Heart Failure?

Congestive heart failure, called chronic heart failure by the Social Security Administration, is the inability of the heart to pump enough oxygenated blood to the body tissues (see Figure 3 below). Congestive or chronic heart failure (CHF) affects about 5 million people in the U.S., and is increasing due to the aging of the population.

The heart’s ability to pump blood may be impaired by a variety of causes including myocardial infarction (heart attack), ischemic heart disease (decreased blood flow to heart muscle, usually as a result of coronary artery disease), and cardiomyopathy. The failure of the ventricles to pump blood efficiently results in blood accumulating in the heart, and enlargement of the ventricles.

Figure 3: The heart pumps blood through an immense network of veins and arteries.

Right Heart Failure

Failure of the right ventricle is known as right heart failure. In right-sided failure, there tends to be congestion (fluid accumulation) in organs such as the liver and peripheral edema (swelling) in the feet, because of pressure transmitted back through the venous system. Cor pulmonale—heart disease caused by lung disease—is the main cause of right-sided failure.

Left Heart Failure

Failure of the left ventricle is known as left heart failure. In left-sided failure, pulmonary edema is expected because of increased pressures transmitted back to the pulmonary vascular system.

Ischemic heart disease affecting the left ventricle is usually responsible for left-sided failure. However, the two sides of the heart do not operate in isolation: failure on one side will be associated with failure of the other side, so there are no abnormal findings that are characteristic of only right or left types of heart failure. See Can I Get Social Security Disability Benefits for Ischemic Heart Disease?

Systolic Failure

Predominant systolic dysfunction or systolic failure is the inability of the heart to contract normally and expel sufficient blood. It is characterized by an enlarged, poorly contracting left ventricle and reduced ejection fraction. Ejection fraction (EF) is the percentage of the blood in the ventricle pumped out with each contraction. Most of the claims for disability benefits seen by the Social Security Administration involve systolic heart failure.

Diastolic Failure

Predominant diastolic dysfunction or diastolic failure is the inability of the heart to relax and fill normally. It is characterized by a thickened ventricular muscle, poor ability of the left ventricle to distend (stretch), increased ventricular filling pressure, and a normal or increased EF. Twenty to 40% of heart failure is due to diastolic dysfunction. Some people have both systolic and diastolic dysfunction.

Symptoms and Signs of Congestive Heart Failure

To establish that you have chronic heart failure for the purpose of receiving Social Security disability benefits, your medical history and physical examination should describe characteristic symptoms and signs of pulmonary or systemic congestion or of limited cardiac output. And these signs and symptoms should be associated with the abnormal findings on appropriate medically acceptable imaging. Factors that cause heart failure, but that can be improved or eliminated, such as heart failure induced by high altitude, arrhythmias, and dietary sodium overload, would not be expected to result in chronic failure.

Symptoms of congestion or of limited cardiac output include:

• Easy fatigue.
• Weakness.
• Shortness of breath (dyspnea) on exertion.
• Coughing.
• Chest discomfort at rest or with activity.
• Shortness of breath on lying flat (orthopnea).
• Sudden shortness of breath while sleeping (paroxysmal nocturnal dyspnea (PND)).
• Cardiac arrhythmias resulting in palpitations, lightheadedness, or fainting.

Signs of congestion may include:

• An enlarged liver (hepatomegaly).
• Fluid accumulation in the abdomen (ascites).
• Increased jugular vein distention or pressure.
• Rales (abnormal breath sounds heard with a stethoscope listening over the lungs, especially the bases of the lungs).
• Peripheral edema (fluid retention and swelling in the extremities).
• Rapid weight gain.

However, these signs need not be found on all examinations because fluid retention may be controlled by treatment.

Prognosis and Mortality in Heart Failure

Available statistics regarding mortality vary, but there is general agreement that, at the time of diagnosis, CHF has a 5-year mortality in the 35-50% range. This very general number shows what a serious diagnosis is involved, but there are great differences in individual mortalities that are determined by age, sex, race, cause of failure, as well as the nature and severity of other medical disorders. For example, mortality is higher for African-Americans than Caucasians, higher for males than females, higher for age than youth, higher in diabetics, and higher in those with hypertension.

Continue to Winning Social Security Disability Benefits for Congestive Heart Failure by Meeting a Listing.

Can I Get Social Security Disability Benefits for Chronic Fatigue Syndrome?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Chronic Fatigue Syndrome?
• About Chronic Fatigue and Disability
• Winning Social Security Disability Benefits for Chronic Fatigue Syndrome by Equaling a Listing
• Residual Functional Capacity Assessment for Chronic Fatigue Syndrome
• Getting Your Doctor’s Opinion About What You Can Still Do

How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Chronic Fatigue Syndrome?

If you have chronic fatigue, Social Security disability benefits may be available to you. To determine whether you are disabled by chronic fatigue, the Social Security Administration will consider whether your chronic fatigue qualifies as a severe medically determinable impairment at Step 2 of the Sequential Evaluation Process. See Chronic Fatigue Syndrome as a Medically Determinable Severe Impairment.If your chronic fatigue qualifies at Step 2, the Social Security Administration considers whether your chronic fatigue is severe enough to equal a listing atStep 3 of th eSequential Evaluation Process. See Winning Social Security Disability Benefits for Chronic Fatigue by Equaling a Listing.

If your chronic fatigue is not severe enough to equal a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your chronic fatigue), to determine whether you qualify for benefits at Step 4 andStep 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Chronic Fatigue Syndrome.

About Chronic Fatigue and Disability

Chronic fatigue is also known as chronic fatigue syndrome (CFS) and immune dysfunction syndrome (CFIDS). It is a very misunderstood disorder, and has been the center of much debate. It has no known proven causes, no definite tests to prove its validity, and no known cures.

It is a complex disorder that is has many signs and symptoms. The most common symptom is extreme fatigue for no reason that is not improved by rest and may get worse with light physical or mental activity.

Over one million people in the United States have been diagnosed with chronic fatigue.

The general pattern is that the person experiences “flu-like” symptoms that do not go away. This usually occurs during a period of great stress in the person’s life. When it first occurs, people think it will pass like the flu.

Chronic Fatigue Syndrome as a Medically Determinable Severe Impairment

The Center for Disease Control Definition

You must have a medically determinable impairment that is severe to satisfy Step 2 of the Sequential Evaluation Process.The Social Security Administration has ruled that chronic fatigue can constitute a medically determinable impairment if a diagnosis is made under the current Center for Disease Control (CDC) diagnostic criteria for chronic fatigue.

The Center for Disease Control defines chronic fatigue as the presence of clinically evaluated, persistent or relapsing chronic fatigue that is new or has a definite beginning (that is, it has not been lifelong) that cannot be explained by any other diagnosed physical or mental disorder, or the result of ongoing exertion. Chronic fatigue is not substantially alleviated by rest, and it results in substantial reduction of previous levels of occupational, educational, social, or personal activities.

Additionally, the current definition of chronic fatigue requires four or more of the following symptoms, all of which must have persisted or recurred during 6 or more consecutive months of illness and must not have pre-dated the fatigue:

• Self-reported impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities.
• Sore throat.
• Tender cervical or axillary lymph nodes.
• Muscle pain.
• Multi-joint pain without joint swelling or redness.
• Headaches of a new type, pattern, or severity.
• Unrefreshing sleep.
• Postexertional malaise lasting more than 24 hours.

Chronic fatigue syndrome usually must be present for at least six months before it is diagnosed and can last for years.

Medical Signs or Laboratory Findings

In addition to the Center for Disease Control criteria, the Social Security Administration requires the presence of medical signs or laboratory findings to demonstrate that a claimant with chronic fatigue syndrome has a medically determinable impairment.

However, no specific etiology or pathology has been established for chronic fatigue. Therefore, any possible signs and laboratory findings to establish the existence of a medically determinable impairment are only examples and are not all-inclusive.

For purposes of Social Security disability evaluation, one or more of the following medical signs clinically documented over a period of at least 6 consecutive months establishes the existence of a medically determinable impairment for individuals with CFS:

• Palpably swollen or tender lymph nodes on physical examination.
• Nonexudative pharyngitis.
• Persistent, reproducible muscle tenderness on repeated examinations, including the presence of positive tender points.
• Any other medical signs that are consistent with medically accepted clinical practice and are consistent with the other evidence in the case record.

Therefore, the following laboratory findings establish the existence of a medically determinable impairment in individuals with chronic fatigue:

• An elevated antibody titer to Epstein-Barr virus (EBV) capsid antigen equal to or greater than 1:5120, or early antigen equal to or greater than 1:640.
• An abnormal magnetic resonance imaging (MRI) brain scan.
• Neurally mediated hypotension as shown by tilt table testing or another clinically accepted form of testing.
• Any other laboratory findings that are consistent with medically accepted clinical practice and are consistent with the other evidence in the case record; for example, an abnormal exercise stress test or abnormal sleep studies, appropriately evaluated and consistent with the other evidence in the case record.

Individuals with chronic fatigue may also exhibit medical signs, such as anxiety or depression, indicative of the existence of a mental disorder. When such medical signs are present and appropriately documented, the existence of a medically determinable impairment is established.

Winning Social Security Disability Benefits for Chronic Fatigue Syndrome by Equaling a Listing

To determine whether you are disabled at Step 3 of the Sequential Evaluation Process,the Social Security Administration usually considers whether your impairment is severe enough to meet or a 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 the Social Security Administration presumes would prevent a person from performing substantial work. If your impairment is severe enough to meet or equal the listing, you will be considered disabled.

The Social Security Administration has no listing for chronic fatigue syndrome. Since CFS is not a listed impairment, you cannot be cannot be found to meet a listed impairment based on your CFS alone. However, the specific findings in your case should be compared to any pertinent listing to determine whether “medical equivalence” may exist. In other words, you may be entitled to Social Security disability benefits if the severity of your condition equals an existing listing for a different impairment.

If you have psychological problems related to CFS, they should be evaluated under the mental disorders listings. The Social Security Administration should consider whether your impairments meet or equal the severity of a mental listing. See Can I Get Social Security Disability Benefits for Depression, Bipolar Disorder, or Mania? and Can I Get Social Security Disability Benefits for Anxiety, Phobias, Panic Attacks, Obsessive Compulsive Disorder, or PTSD?

Continue to Residual Functional Capacity Assessment for Chronic Fatigue Syndrome.

Can I Get Social Security Disability Benefits for Crohn’s Disease?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Crohn’s Disease?
• About Crohn’s Disease and Disability
• Winning Social Security Disability Benefits for Crohn’s Disease by Meeting a Listing
• Residual Functional Capacity Assessment for Crohn’s Disease
• 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 Crohn’s Disease?

If you have Crohn’s disease, Social Security disability benefits may be available. To determine whether you are disabled by Crohn’s disease, Social Security Administration first considers whether your Crohn’s disease is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Crohn’s Disease by Meeting a Listing. If you meet or equal a listing because of Crohn’s disease, you are considered disabled.

If your Crohn’s disease 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 illness), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Crohn’s Disease.

About Crohn’s Disease and Disability

What Is Crohn’s Disease?

Crohn’s disease is a chronic, inflammatory disease of the gastrointestinal tract (see Figure 1 below) that produces symptoms such as severe abdominal pain, cramping, nausea, fatigue, diarrhea, and insomnia.

With Crohn’s disease, the body’s immune system attacks the gastrointestinal tract, causing inflammation.

Other Symptoms

Crohn’s disease may involve the entire alimentary tract from the mouth to the anus.

In addition to the common symptoms of abdominal pain, cramping, nausea, fatigue, diarrhea, and insomnia, you may also experience fecal incontinence, rectal bleeding, fever, vomiting, arthralgia (joint pain), abdominal tenderness, palpable abdominal mass (usually inflamed loops of bowel) and perineal disease. You may also have weight loss or other indications of malnutrition.

Figure 1: The human gastrointestinal tract.

When Does it Occur?

Crohn’s disease can occur at any age. However, it is most common for it to begin either when you are in your teens and twenties or between your fifties and seventies.

Cause and Treatment

The cause of Crohn’s disease is unknown, and it is rarely curable. Recurrence may be a lifelong problem even after surgery. Treatment is usually limited to controlling the symptoms.

Related Conditions

Crohn’s disease is a form of inflammatory bowel disease (IBD), which includes both Crohn’s disease and ulcerative colitis. The various forms of inflammatory bowel disease share similar symptoms and treatments.

Crohn’s disease affects the small intestine. Ulcerative colitis affects the large intestine (the colon).

Winning Social Security Disability Benefits for Crohn’s Disease 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 Crohn’s disease is severe enough to meet or equal the Crohn’s disease 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. You will be considered disabled if your Crohn’s disease is severe enough to meet or equal the Crohn’s disease listing.

The listing for Crohn’s disease is 5.06, which has two parts: A and B. You will be disabled if you meet either part.

Meeting Social Security Administration Listing 5.06A for Crohn’s Disease

A Social Security disability claimant with Crohn’s disease meets listing 5.06A and is disabled if he or she has had sufficient narrowing of the intestine.

Listing 5.06A requires two hospitalizations for bowel obstruction at least 60 days apart within a six-month period. This hospitalization requirement means that only the most severe chronic cases qualify under listing 5.06A.

If the complications are eliminated by surgery, then you do not qualify under part A. In many instances, surgery does produce long-term benefit when combined with the proper diet and medication.

Meeting Social Security Administration Listing 5.06B for Crohn’s Disease

A Social Security disability claimant with Crohn’s disease meets listing 5.06(B) and is disabled if he or she has two of the following within a consecutive 6-month period while being treated:

• 5.06B.1 Anemia with hemoglobin of less than 10.0 g/dL.
• 5.06B.2. Serum albumin of 3.0 g/dL or less.
• 5.06B.3. Clinically documented tender abdominal mass palpable on physical examination with abdominal pain or cramping that is not completely controlled by prescribed narcotic medication.
• 5.06B.4. Perineal disease with a draining abscess or fistula, with pain that is not completely controlled by prescribed narcotic medication.
• 5.06B.5. Involuntary weight loss of at least 10 percent from baseline.
• 5.06B.6. Need for supplemental daily enteral nutrition via a gastrostomy or daily parenteral nutrition via a central venous catheter.

Continue to Residual Functional Capacity Assessment for Crohn’s Disease.

Can I Get Social Security Disability Benefits for Cystic Fibrosis?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Cystic Fibrosis?
• About Cystic Fibrosis and Disability
• Winning Social Security Disability Benefits for Cystic Fibrosis by Meeting a Listing
• Residual Functional Capacity Assessment for Cystic Fibrosis
• 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 Cystic Fibrosis?

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

About Cystic Fibrosis and Disability

What Is Cystic Fibrosis?

Cystic fibrosis is a severe genetic disease that causes production of excess mucus. It has major effects on the lungs and the digestive system. In cystic fibrosis the function of the exocrine glands is impaired. Exocrine glands secrete substances outside of the body or into body cavities. Examples include the mucous glands lining the bronchial tree, sweat glands, and glands in the pancreas that secrete digestive enzymes.

There are about 30,000 cases of cystic fibrosis in the U.S., but around 5% of the population unknowingly carries a mutated cystic fibrosis gene. The disorder principally affects whites of northern European descent, but all races can be affected.

Presently, there is no cure for cystic fibrosis. Care is mostly supportive—pulmonary hygiene to drain mucus from the lungs and prevent the onset of pneumonia, antibiotics to treat infection, replacement pancreatic enzymes, exercise, and good nutrition.

Lung Problems in Cystic Fibrosis

The lung problem in cystic fibrosis results from thick, dry bronchial mucus that cannot be adequately cleared from the airways. The excess mucus leads to coughing and sputum production sometimes with coughing up of blood (hemoptysis). Pneumonia and other lung infections are also a frequent problem. Chronic lung infections can lead to chronic obstructive lung disease.

The thick mucus needs to be removed from the lungs with frequent pulmonary hygiene, consisting of postural drainage and chest percussion. This is done by clapping with cupped hands on the front and back of the chest while the person lies with his or her head over the edge of a bed so that gravity helps clear the secretions. Mechanical devices may also be used for chest percussion.

Medications to thin mucous secretions (mucolytics) and bronchodilators to improve air flow are typical components of treatment. Additionally, an inhaled enzyme can help break down cellular material accumulating in the bronchi.

About 80% of cystic fibrosis patients die from lung disease, mostly related to infection.

Digestive Problems in Cystic Fibrosis

Thickened secretions can block digestive enzymes secreted by the pancreas. About 90% of cystic fibrosis patients have some degree of this problem. They must take pancreatic enzymes to digest food. Additionally, vitamin supplements are needed.

Thick, dry intestinal secretions can cause intestinal obstruction that requires surgery to clear. Stool softeners may help; enemas and intestinal lavage (rinsing) may be needed. Exercise is always important, to the extent that the patient can do so.

Other Problems Associated With Cystic Fibrosis

All cystic fibrosis problems are not necessarily pulmonary or digestive. Other problems can be associated with cystic fibrosis, including undescended testicles, diabetes mellitus, inguinal hernias, sinusitis, heart failure, and fibrosis of bile ducts (biliary cirrhosis). See Can I Get Social Security Disability Benefits for Diabetes?

Diagnosis of Cystic Fibrosis

The diagnosis of cystic fibrosis is made with a test called pilocarpine iontophoresis in which a sample of the person’s sweat is collected and analyzed for presence of sodium or chloride. People with cystic fibrosis have elevated levels, which is why their skin tastes salty. The diagnosis of cystic fibrosis has always been made long before a claimant files an application for disability benefits, but sometimes the Social Security Administration has to purchase the test to verify the diagnosis when a claimant’s medical records cannot be obtained.

Prognosis for Cystic Fibrosis

Despite the absence of a cure, improved treatment has steadily increased survival. Because of increased survival the Social Security Administration sees adult claimants with cystic fibrosis, as well as children. In 2008, the median predicted age of survival rose to 37.4 years, up from 32 in 2000.

Winning Social Security Disability Benefits for Cystic Fibrosis 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 breathing difficulties are severe enough to meet or equal the cystic fibrosis 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 cystic fibrosis is severe enough to meet or equal the cystic fibrosis listing, you will be considered disabled.

The listing that applies to lung problems from cystic fibrosis is 3.04. It has 3 parts, A, B, and C.

You will meet the listing and qualify for disability benefits if you meet any part.

Digestive system problems are evaluated under the digestive system listings. You may qualify for disability benefits with a combination of pulmonary and digestive impairments even if neither alone is sufficient to meet a listing.

Meeting Social Security Administration Listing 3.04A for Cystic Fibrosis

You will meet part A of listing 3.04 if you have cystic fibrosis with an FEV1 equal to or less than the appropriate value specified in Table IV corresponding to your height without shoes.

Part A involves evaluation of the results of spirometric testing. Spirometric testing requires you to exhale into a device called a spirometer, which measures the volume of air you can inhale and exhale. FEV1 means forced expiratory volume in one second. Spirometry is the most important test for evaluating obstructive lung disease. FEV1 decreases in proportion to the severity of the lung disease. In other words, the lower your FEV1, the more severe your lung disease is.

Table IV shows the threshold values for the FEV1 that meet the listing for various heights. In reality, gender and age affect normal values but are not taken into account in part A. Since older women have somewhat lower normal predicted values for a given height than men, failure of the table to make a distinction is to the maximum advantage of older women.

Meeting Social Security Administration Listing 3.04B for Cystic Fibrosis

You will meet part B of listing 3.04 if you have cystic fibrosis and episodes of bronchitis or pneumonia or hemoptysis (coughing up blood–more than bloodstreaked sputum) or respiratory failure, requiring physician intervention, occurring at least once every 2 months or at least 6 times a year. Each inpatient hospitalization for longer than 24 hours for treatment counts as two episodes, and an evaluation period of at least 12 consecutive months must be used to determine the frequency of episodes.

Not every episode counts. Episodes must be prolonged 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, to meet Listing 3.04B, you must have episodes that require a trip to the ER or treatment by a doctor to control.

Documentation of your medical treatment is the key to winning a disability claim under listing 3.04B. Documentation should include hospital, emergency facility and/or physician records indicating the dates of treatment; clinical and laboratory findings, such as the results of spirometry and arterial blood gas studies (ABGS); the treatment administered; the time period required for treatment; and your response to treatment. The medical evidence must also include information documenting your adherence to a prescribed regimen of treatment as well as a description of physical signs.

Meeting Social Security Administration Listing 3.04C for Cystic Fibrosis

You will meet part C of listing 3.04 if you have cystic fibrosis and persistent pulmonary infection accompanied by superimposed, recurrent, symptomatic episodes of increased bacterial infection occurring at least once every 6 months and requiring intravenous or nebulization antimicrobial therapy.

The purpose of part C is to document severe chronic lung disease resulting from infection. The Social Security Administration determines whether you meet the listing by considering factors such as medical history, clinical findings, symptoms, sputum cultures, imaging studies like chest X rays, or direct visualization of bronchi with bronchoscopy.

Part C requires only that the infection be persistent. It does not require any particular level of severity. Furthermore, it does not require symptoms, such as chest discomfort or malaise, although these would support the diagnosis of continuing infection, as would a persistent low-grade fever. Even mild, persistent infection implies ongoing deterioration in the lungs, although it might be slow. In fact, deteriorating pulmonary function studies, like a worsening FEV1, in the absence of obvious pneumonia support the existence of some type of chronic infection.

Continue to Residual Functional Capacity Assessment for Cystic Fibrosis.

Can I Get Social Security Disability Benefits for Depression, Bipolar Disorder, or Mania?

• How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Bipolar Disorder, Depression, or Mania?
• About Affective Disorders and Disability
• Winning Social Security Disability Benefits for Depression, Mania, or Bipolar Disorder by Meeting a Listing
• Residual Functional Capacity Assessment for Depression, Mania, and Bipolar Disorder
• 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 Bipolar Disorder, Depression, or Mania?

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

About Affective Disorders and Disability

What Are Affective Disorders (Mood Disorders)?

Affective disorders are really more appropriately called mood disorders. An affect is an emotion, manifest and observable in thinking and/or behavior. Mood is a more sustained and pervasive emotional element of mental life. Affective disorders include:

• Mania.
• Depression.
• Bipolar Disorder.

What Is Mania?

A person with mania has a distinctly elevated mood, usually euphoric or elated. The person has a grossly inappropriate energy and enthusiasm for everything. He or she has grandiose plans that cannot be achieved considering the person’s actual abilities and assets. But the person is not aware of this fact. To strangers, such a person may appear charismatic and dynamic, but, to those who know him or her, obviously functioning in an abnormal state.

Dynamic, enthusiastic, and energetic people are not necessarily manic. They are organized and productive while engaging in appropriate behaviors. The manic, on the other hand, has incomplete and disorganized behaviors from grandiose efforts to accomplish goals beyond his or her capacity. Normal people know they will fail at tasks that are beyond their capacity, and apply judgment in taking on tasks. But in mania, the individual characteristically takes on projects beyond his or her ability in a general behavioral pattern affecting every aspect of life, without appreciation of consequences or chances of success. The very high arousal state impairs judgment.

What Is Depression?

Depression has the opposite characteristics of mania. Instead of being in a euphoric mood, the person has limited activities, interests, and lowered self-esteem. A depressed person sees few possibilities for happiness. This narrowed viewpoint is associated with feelings of hopelessness and even despair. In the extreme case, even the ability to take care of personal hygiene may be impaired.

What Is Bipolar Disorder?

Bipolar disorder is diagnosed when the individual’s mood fluctuates between the extremes of depression and mania. The cycling between depression and mania may be very rapid (e.g., days) or occur over long periods of time (e.g., years).

Advanced brain imaging has established that bipolar disorder is associated with brain tissue loss. Tissue loss increases with age and is also worse in proportion to the number of relapses. Changes are most prominent in areas affecting face recognition, motor coordination, and memory—the fusiform gyrus, the cerebellum, and the hippocampus, respectively. The reason for brain shrinkage is not clear. But this is something the Social Security Administration adjudicator should keep in mind, especially if you have a long history of bipolar disorder with multiple relapses. In these instances, you may need neuropsychological testing in addition to a mental status evaluation to evaluate whether you are disabled.

Drug Treatments

Mania can often be effectively controlled with the drug lithium carbonate. Lithium is potentially toxic and those who take it should have periodic blood levels checked by a medical doctor.

While in the past treatment for bipolar disorder was limited to lithium, now a number of medications can be used:

• The antiepileptic drugs carbamazepine (Tegretol), lamotrigine (Lamictal), and divalproex (Epival, Depakote);
• The antipsychotic drugs olanzapine (Zyprexa) and quetiapine (Seroquel); or
• Various combinations of these.

Tamoxifen (Nolvadex), long used to treat breast cancer, has been found helpful in treating mania in bipolar disorder. Considering all of these drugs, a wide spectrum of side-effects are possible.

Claimants taking these medications should always have their claims reviewed by a physician. Because of the potential toxicity of drugs used to treat bipolar disorder and other serious mental disorders, the Social Security Administration should not to allow adjudication without review of the medical evidence by a medical doctor. A psychiatrist can evaluat

e both the mental disorder and drug toxicity. Clinical psychologists working for the Social Security Administration are not qualified to evaluate drug toxicity information. However, it is common practice for the Social Security Administration to permit severity assessment by psychologists alone in cases of mental disorders being treated by various medications. For example, a psychologist should not be expected to recognize that a claimant’s complaint of sleepiness could be due to medication, yet that fact could limit the claimant’s ability to do jobs requiring alertness, work at unprotected heights, or around hazardous machinery.

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 treating psychiatrist’s attention and to the Social Security Administration.

Continue to Winning Social Security Disability Benefits for Depression, Mania, or Bipolar Disorder by Meeting a Listing.

Can I Get Social Security Disability Benefits for Diabetes?

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

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

If you have diabetes,Social Security disability benefits may be available. To determine whether you are disabled by diabetes, the Social Security Administration first considers whether your diabetes is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Diabetes by Meeting a Listing.

If your diabetes is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your diabetes), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Diabetes.

About Diabetes and Disability

What Is Diabetes?

The complete name for diabetes is diabetes mellitus. Also known as “sugar” diabetes, diabetes mellitus is a hormonal disorder. The cells of the body need a form of sugar called glucose for energy. The body breaks down various carbohydrates in the diet to glucose. Glucose then circulates to the body’s tissues through the blood. But glucose cannot get from the blood to the inside of the cells where the cells can use it, unless the hormone insulin is also present. Insulin permits passage of glucose through the cell membrane.

Insulin is secreted by the pancreas. The pancreas is an elongated organ located behind the stomach. Special cells, known as the Islets of Langerhans, are spread throughout it. These cells produce insulin that is released into the blood. Diabetes occurs when the pancreas does not produce any or enough insulin or when the body is unable to use effectively the insulin that is produced. High blood sugar results as glucose accumulates in the blood because it cannot get into the cells of the body.

The Social Security Administration sees many claimants who are afflicted with diabetes. Diabetes mellitus affects the entire body, and may be mild, moderate, or severe. Diabetes is a major cause of illness, disability, and death. The number of cases of diabetes is increasing markedly in the U.S. as a result of obesity, inadequate exercise, and junk food. More and more children are becoming diabetic at younger ages, as are adults.

There are two main types of diabetes mellitus, Type 1 diabetes and Type 2 diabetes.

Type 1 Diabetes

Type 1 diabetes is the most severe form of diabetes. Older names for Type 1 include juvenile diabetes, juvenile onset diabetes, and insulin-dependent diabetes mellitus (IDDM). IDDM is misleading because other types of diabetes besides Type 1 may require insulin. Type 1 appears during childhood or early adulthood. It is an autoimmune disorder in which cells in the immune system called T lymphocytes damage the insulin-producing cells in the pancreas. Then the level of glucose in the blood becomes abnormally high, since glucose cannot get into the cells without enough insulin. Persons with Type 1 diabetes must take injections of insulin to correct the problem.Type 1 diabetes accounts for 5% to 10% of total cases of diabetes.

Medical research continues in an effort to prevent Type 1 diabetes mellitus, but so far it has not been successful. Unfortunately, there is no single “diabetic gene” that could be replaced with gene therapy to cure this disease; the immune system abnormalities are numerous and complex. Type 1 diabetes can result in complete destruction of the pancreatic islet cells over a period as short as 3 years. This means that Type 1 diabetes develops quickly, and a person with Type 1 diabetes needs to inject insulin early in the course of the disease.

Because of the marked fall in insulin, the symptoms and complications of Type 1 diabetes can be severe. Uncontrolled severe Type 1 diabetics typically have excessive urination, thirst, and appetite with weight loss. But they may have no appetite. And they may experience weakness, abdominal pain, nausea, and vomiting, along with sleepiness, lethargy, or even coma. A person may have these symptoms when first diagnosed. And a person with Type 1 diabetes may have these symptoms anytime he or she stops taking insulin.

Type 2 Diabetes

The most common form (90%) of diabetes mellitus is Type 2. Those with Type 2 diabetes may or may not need to take insulin injections. Often Type 2 diabetes can be controlled with diet, weight loss, exercise, and oral medications. Type 2 diabetes is also known as non-insulin dependent diabetes mellitus (NIDDM) in those who do not require insulin. Unlike Type 1 diabetes, Type 2 is not an autoimmune disorder, though the immune system and genetics may play a role in its development and progression.

The major problem with Type 2 diabetes is not lack of insulin, but rather insulin resistance. Insulin resistance means the cells of the body are not able to use insulin effectively. The insulin levels in Type 2 diabetics may be decreased, normal, or increased, but they are usually increased. Insulin resistance, and the severity of the diabetes, is markedly increased by obesity and lack of exercise.

The oral medications that many Type 2 diabetics take to control blood glucose work in one of two ways. Either they increase the amount of insulin that the pancreas is able to secrete. Or they improve the ability of the cells to use insulin thereby reducing insulin resistance. Studies have shown that exercise can decrease insulin resistance as much as oral medication.

Historically, Type 2 diabetes developed slowly over a period of years, and a person did not need to take insulin until he or she had the disease for a while. Type 2 diabetes has been known as “adult-onset diabetes mellitus” or “maturity-onset diabetes mellitus,” because it usually developed after age 40. Now in the U.S. even children are developing Type 2 diabetes. Onset at earlier ages is occurring because of increasing childhood obesity, lack of exercise, and access to high-fat junk food. The wave of Type 2 diabetes has not yet reached a peak, as the effects of the child obesity epidemic have not had time to fully develop, and the adult population continues to become increasingly obese. Increasing numbers of claims for Social Security disability benefits based on diabetes can be expected.

Other Types of Diabetes

A few cases of diabetes mellitus are not Type 1 or 2. Gestational diabetes appears during pregnancy. The problem arises from a combination of insufficient insulin and the effects of hormonal changes associated with pregnancy. After pregnancy, the diabetes will usually abate, but 5% to 10% of gestational diabetes cases are actually Type 2 diabetics. A person with gestational diabetes has an increased risk for eventual development of diabetes, even if the gestational diabetes resolves. Various medical problems like surgery, malnutrition, infection, pancreatic trauma, and drugs can be enough to push a person over into diabetes and account for about 1% to 5% of all diabetics.

Diagnosis of Diabetes Mellitus

Diabetes is diagnosed when blood sugar (glucose) levels are high. Medical authorities disagree about how high glucose levels must be for the diagnosis. Normal fasting blood glucose (FBG) levels are no higher than 110 mg% (110 mg/dL); some authorities put the upper limit of normal at 115 mg%. It is generally agreed that a FBG of 140 mg/dL or greater on at least two separate days should be considered diagnostic of diabetes mellitus in anyone. This threshold is the “gold standard” for diagnosing diabetes.

The American Diabetes Association (ADA) has lower plasma glucose thresholds for diagnosing diabetes. The criteria for the diagnosis of diabetes mellitus according to the recommendations of the American Diabetes Association are:

• Random (casual) plasma glucose level over 200 mg/dL in the presence of symptoms of diabetes (the classic symptoms including excessive urination, excessive thirst, and unexplained weight loss);

Or

• A fasting plasma glucose level over 126 mg/dL;

Or

• An oral glucose tolerance test with a two hour post-load plasma glucose level over 200 mg/dL.

To establish the diagnosis of diabetes mellitus, according to the ADA, any of the above three tests must be done at least twice and on different days. However, not all endocrinologists subscribe to the ADA diagnostic criteria.

Some individuals are diagnosed as having “pre-diabetes.” The diagnosis is based on glucose levels that are higher than normal, but below the thresholds for diagnosing diabetes. Millions of Americans are pre-diabetic and have increased risk of strokes, peripheral vascular disease, heart attacks, and diabetes.

Ketoacidosis

Ketoacidosis is a serious condition that can occur in people with Type 1 diabetes. You may meet the diabetes listing and be eligible for social security disability benefits if you have episodes of ketoacidosis one every two months on average. See Meeting Listing 9.08B for Diabetes.

It results when insulin levels approach zero. It is called ketoacidosis because compounds called ketones are released into the blood and secreted in the urine and breath and the ph of the blood becomes lower than normal making it acidic. Symptoms of ketoacidosis include dehydration, weight loss, mental confusion, nausea and vomiting, rapid and deep breathing, and, if untreated, unconsciousness, coma, and death.

Ketoacidosis develops in the following way. When insulin levels are very low, the cells are starved for glucose, even though glucose is in the blood stream. In an attempt to compensate for the apparent lack of glucose, the pancreas releases the hormone glucagon. Glucagon causes the liver to convert sugar it has stored as glycogen to glucose. This additional glucose increases blood sugar levels even more, leading to a condition known as hyperglycemia. Hyperglycemia results because only the brain can use the large amounts of glucose being produced. Other tissues cannot use the glucose without insulin. Since the cells have no usable energy source, the body begins to break down fat for energy. As part of the fat metabolism process, the liver releases chemicals known as ketones into the blood stream. These ketones increase the acidity of the blood, so that the pH drops below its normal range of 7.35–7.45.

The decrease in pH in acidosis can be measured with an arterial blood gas study (ABGS). In addition to the decrease in pH, ketoacidosis on ABGS will show a decrease in bicarbonate (strongCO3), a normal value being about 21–28 meq/L. Decreased carbon dioxide gas pressure (pCO2) will be present, normal PaCO2 being about 35–45 mm Hg.

Ketoacidosis can be confirmed by the detection of acetone or acetoacetate in blood or urine. Dipsticks can be used for urine, so more formal laboratory tests are not necessarily required. There are also other forms of testing (e.g., Acetest tablets).

People with Type 2 diabetes rarely experience ketoacidosis. The reason for this is unclear, since they can have severe hyperglycemia and in some instances require insulin.

Complications of Diabetes

Diabetes is a terrible disease that can affect all tissues in the body. The major types of severe organ damage caused by diabetes mellitus are:

Neuropathy (nerve damage)

Diabetes commonly produces progressive damage in peripheral nerves (the nerves outside the brain and spinal cord). The damage often leads to numbness in the feet and legs. This is called sensory peripheral neuropathy and is the most common type of neuropathy (see Figure 1 below). If you have diabetic neuropathy, you may meet qualify for Social Security disability benefits by meeting a listing. See Meeting Social Security Administration Listing 9.08A for Diabetes.

Diabetic sensory peripheral neuropathy can also result in a lack of position sense (proprioception) in the legs, so that the diabetic has difficulty balancing and walking normally. Diabetes may also produce a motor peripheral neuropathy. This means the motor nerves that activate muscles can be damaged causes the muscles to be weak. Nerve conduction studies (NCS) can objectively measure the severity of peripheral neuropathy. A second type of neuropathy common to diabetics is autonomic neuropathy (see Figure 2 below). Inautonomic neuropathy, autonomic nerves (nerves that regulate involuntary body functions) are damaged. For example, damage may occur to cardiac nerves that help regulate heart rhythm, gastric nerves that move the stomach walls, or nerves in the walls of arteries that help adjust vessel diameter to maintain blood pressure with body position changes. After peripheral or autonomic neuropathy has occurred, it does not necessarily improve—especially if it is advanced. Furthermore, a person’s blood glucose may normalize with treatment and his or her nerve conduction velocity values may then return to normal, but the individual may still experience the symptoms of peripheral neuropathy. The Social Security Administration should not presume that a claimant with neuropathy that does not improve as documented by the treating physician’s examination is not credible on the basis of an improved NCS alone.

NCS cannot be done for autonomic neuropathy since those nerves are not normally accessible.

Figures 1 and 2: Sensory peripheral neuropathy (top) and autonomic neuropathy bottom.

Diabetic Retinopathy

Diabetic retinopathyis one of the most frequent causes of blindness in the U.S., and the Social Security Administration sees many such claimants. If your diabetic retinopathy is severe, you may qualify for Social Security disability benefits by meeting a listing. See Meeting Listing 9.08C for Diabetes.

Kidney Failure

One of the major causes of kidney failure in the U.S. is diabetes mellitus.

Heart Disease

Diabetes is a major contributor to the development of coronary artery disease and peripheral vascular arterial disease, as well as additional complications such as heart failure.

Amputation

Diabetes is a major cause of the need for amputation of lower extremities. This complication occurs because the diabetes compromises immunity and resistance to bacterial infection, and because diabetes decreases blood flow in small arterial vessels. These facts mean a person can develop an infection from a minor injury to the foot when trimming the toenails. Infection is difficult to control when blood flow is compromised and immunity impaired; antibiotics may not be effective. Tissue death (gangrene) may require amputation, and sometimes repeated amputations.

Stroke

Because of vascular damage, people with diabetes have a high rate of strokes. See Can I Get Social Security Disability Benefits After a Stroke?

High Blood Sugar and Diabetic Complications

Whether in Type 1 or 2 diabetes mellitus, high blood sugar or hyperglycemia has relentless destructive effects on most major body systems. Regulation of blood glucose levels with insulin, or other treatment is known as “control.” In general, tighter control of blood glucose with insulin injections, or medication, and diet and exercise, means better control of complications. But good control will not necessarily reverse damage that has already been done, although improvement may be possible. Other factors are in play besides blood glucose control, because good control does not necessarily stop progression of a diabetic complication once damage has been done. However, good glucose control will slow the progression.

Good glucose control is difficult to achieve because there is currently no way to deliver insulin or other glucose-controlling drugs with the same degree of precision as a normal human body. Pancreatic transplantation can be beneficial to patients with severe complications and difficult to control diabetes, but this is not a solution for most in view of possible complications with the transplant itself. Understandably, people do not like having to inject themselves with insulin. Insulin pumps have been in existence for some years. More recent experimental innovations have been inhaled insulin and insulin patches.

Some diabetics have higher glucose levels due to poor compliance with treatment; when non-compliance is an issue, it will usually be noted in the treating physician’s medical records. Obvious intentional non-compliance leading to severe hyperglycemia and hospitalization seems to be more of a problem with some teenagers than adults. In other instances, a diabetic may have insufficient money for medication, or have a mental disorder like major depression, schizophrenia, or mental retardation. Some claimants who have to inject insulin have difficulty seeing well enough to draw up the proper dose of insulin.

Hard to Control or Brittle Diabetes

Some cases of diabetes are difficult to control even though the patient carefully follows the prescribed treatment. These are cases of brittle diabetes in which the blood glucose levels vary widely and constant adjustments have to be made in insulin doses. The Social Security Administration should take into account the presence of brittle diabetes, but this is difficult to do if the treating doctor’s records are inadequate. Difficult to control diabetes tends to occur when insulin levels fall to zero, because there is no natural insulin to help cushion swings in blood glucose. Poor compliance with treatment and highly variable emotional states can contribute to difficult control; emotions influence the levels of hormones that affect the regulation of blood glucose. However, this subject is not fully understood. See Brittle Diabetes and Residual Functional Capacity.

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

Can I Get Social Security Disability Benefits for Soft Tissue Injuries / Burns?

• How Does the Social Security Administration Decide if I Quality for Disability Benefits for Soft Tissues Injuries / Burns?
• About Soft Tissue Injuries / Burns and Disability
• Winning Social Security Disability Benefits for Soft Tissue Injuries / Burns by Meeting a Listing
• Residual Functional Capacity Assessment for Soft Tissue Injuries / Burns
• 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 Soft Tissue Injuries / Burns?

If you have soft tissue injuries / burns, Social Security disability benefits may be available. To determine whether you are disabled by soft tissue injuries / burns, the Social Security Administration first considers whether your soft tissue injuries are severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Soft Tissue Injuries by Meeting a Listing.

If your soft tissue injury / burn is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your soft tissue injuries), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Soft Tissue Injuries.

About Soft Tissue Injuries / Burns and Disability

What Is a Soft Tissue Injury?

The Social Security Administration allows a disability for soft tissue injury (e.g., burns) of an upper or lower extremity, trunk, or face and head.

Examples of soft tissue injuries include nerve injuries, injuries to tendons and ligaments, injuries to arteries and veins, injuries to the lymphatic system, injuries to muscle, and injuries to skin.

The most likely accidents to produce these types of injuries are automobile, motorcycle, and work-related accidents.

In some cases, surgery may be required to restore function to a limb, such as vascular repair, re-attachment of ligaments and tendons, as well as nerve, vascular, and tendon grafts.

Severe burns are particularly likely to require extensive and prolonged reconstructive surgery to deal with scarring after the burn injury itself has healed.

Degrees of Burning

The various degrees of burning injury are as follows (see Figures 1 – 4 below):

• First degree: the injury is limited to the outer layer of skin (epidermis).
• Superficial second degree: there is injury to both the outer layer of skin (epidermis) and the outer layer of the dermis (living skin layer beneath the epidermis).
• Deep second degree: There is injury through the epidermis and deep into the dermis.
• Third degree: There is full-thickness injury through the epidermis and dermis into the fat layer beneath the skin (subcutaneous fat).
• Fourth degree: there is injury through the skin and subcutaneous fat into underlying muscle or bone.

Figure 1: Features of normal human skin.

Figure 2: A first-degree burn.

Figure 3: A second-degree burn.

Figure 4: A third-degree burn.

How Are Burns Evaluated?

Electrical, chemical, or thermal burns frequently affect other body systems (e.g., musculoskeletal, special senses and speech, respiratory, cardiovascular, renal, neurological, or mental).

Therefore, the Social Security Administration evaluates burns the way it evaluates other disorders that can affect the skin and other body systems. That is, it uses the listing for the predominant feature of your impairment.

For example, if your soft tissue injuries are under continuing surgical management, then your impairment is evaluated under the 1.08 listing for soft tissue injuries. However, if your burns do not meet the requirements of listing 1.08 and you have extensive skin lesions that result in a very serious limitation that has lasted or can be expected to last for a continuous period of at least 12 months, the Social Security Administration will evaluate them under a different listing (listing 8.08).

When to Determine the Claim

If you have extensive second or third degree burns to the hands, elbows, or knees that have just begun treatment at the time of application for benefits, the Social Security Administration should not guess that full function will be restored. Rather, the claim should be held for some months until a realistic assessment of probable outcome can be determined. By then, the long-term surgical management plan will have acquired more definite form.

Winning Social Security Disability Benefits for Soft Tissue Injuries 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 burn injuries are severe enough to meet or equal a 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 Social Security Administration presumes would prevent a person from performing substantial work. If your burn injuries are severe enough to meet or equal the listing, you will be considered disabled.

Listing 1.08

The Social Security Administration listing for soft tissue injury is 1.08. That listing applies to soft tissue injury (e.g., burns) of an upper or lower extremity, trunk, or face and head that is under continuing surgical management for the purpose of the salvage or restoration of major function, but the major function was not restored or is not expected to be restored within 12 months.

Meeting Listing 1.08 for Soft Tissue Injuries

This listing applies only to people who are under the ongoing care of a surgeon who is treating extensive soft tissue injuries. If you have soft tissue injuries that are not healed, but you are not under the continuing care of a surgeon, then you cannot qualify under this listing.

To qualify for a disability under this listing, the Social Security Administration must be able to obtain medical evidence showing a definite treatment plan by the surgeon. Vague statements by the surgeon involving possibilities for further surgery, or that you “will be disabled for 12 months” are not sufficient.

The phrase “under continuing surgical management” in the listing means that you are undergoing surgical procedures and any other associated treatments for the purpose of salvaging or restoring the functional use of the affected part. The treatment may include such things as post-surgical procedures, surgical complications, infections, or other medical complications, related illnesses, or related treatments that delay the individual’s attainment of maximum benefit from therapy.

The listing requires that a “major function” is not able to be restored due to a soft tissue injury of the upper or lower extremity, trunk or face.

A major function of the face and head means activities involving vision, hearing, speech, mastication (chewing), and the initiation of the digestive process.

After maximum benefit from therapy has been achieved (i.e., there have been no significant changes in physical findings or on appropriate medically acceptable imaging for any 6-month period after the last definitive surgical procedure or other medical intervention), you are evaluated on the basis of your residual limitation.

A finding that the listing is met must be based on a consideration of the symptoms, signs, and laboratory findings associated with recent or anticipated surgical procedures and the resulting recuperative periods, including any related medical complications, such as infections, illnesses, and therapies that impede or delay the efforts toward restoration of function.

Continue to Residual Functional Capacity Assessment for Soft Tissue Injuries.

Can I Get Social Security Disability Benefits for Diabetes?

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

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

If you have diabetes,Social Security disability benefits may be available. To determine whether you are disabled by diabetes, the Social Security Administration first considers whether your diabetes is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Diabetes by Meeting a Listing.

If your diabetes is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your diabetes), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Diabetes.

About Diabetes and Disability

What Is Diabetes?

The complete name for diabetes is diabetes mellitus. Also known as “sugar” diabetes, diabetes mellitus is a hormonal disorder. The cells of the body need a form of sugar called glucose for energy. The body breaks down various carbohydrates in the diet to glucose. Glucose then circulates to the body’s tissues through the blood. But glucose cannot get from the blood to the inside of the cells where the cells can use it, unless the hormone insulin is also present. Insulin permits passage of glucose through the cell membrane.

Insulin is secreted by the pancreas. The pancreas is an elongated organ located behind the stomach. Special cells, known as the Islets of Langerhans, are spread throughout it. These cells produce insulin that is released into the blood. Diabetes occurs when the pancreas does not produce any or enough insulin or when the body is unable to use effectively the insulin that is produced. High blood sugar results as glucose accumulates in the blood because it cannot get into the cells of the body.

The Social Security Administration sees many claimants who are afflicted with diabetes. Diabetes mellitus affects the entire body, and may be mild, moderate, or severe. Diabetes is a major cause of illness, disability, and death. The number of cases of diabetes is increasing markedly in the U.S. as a result of obesity, inadequate exercise, and junk food. More and more children are becoming diabetic at younger ages, as are adults.

There are two main types of diabetes mellitus, Type 1 diabetes and Type 2 diabetes.

Type 1 Diabetes

Type 1 diabetes is the most severe form of diabetes. Older names for Type 1 include juvenile diabetes, juvenile onset diabetes, and insulin-dependent diabetes mellitus (IDDM). IDDM is misleading because other types of diabetes besides Type 1 may require insulin. Type 1 appears during childhood or early adulthood. It is an autoimmune disorder in which cells in the immune system called T lymphocytes damage the insulin-producing cells in the pancreas. Then the level of glucose in the blood becomes abnormally high, since glucose cannot get into the cells without enough insulin. Persons with Type 1 diabetes must take injections of insulin to correct the problem.Type 1 diabetes accounts for 5% to 10% of total cases of diabetes.

Medical research continues in an effort to prevent Type 1 diabetes mellitus, but so far it has not been successful. Unfortunately, there is no single “diabetic gene” that could be replaced with gene therapy to cure this disease; the immune system abnormalities are numerous and complex. Type 1 diabetes can result in complete destruction of the pancreatic islet cells over a period as short as 3 years. This means that Type 1 diabetes develops quickly, and a person with Type 1 diabetes needs to inject insulin early in the course of the disease.

Because of the marked fall in insulin, the symptoms and complications of Type 1 diabetes can be severe. Uncontrolled severe Type 1 diabetics typically have excessive urination, thirst, and appetite with weight loss. But they may have no appetite. And they may experience weakness, abdominal pain, nausea, and vomiting, along with sleepiness, lethargy, or even coma. A person may have these symptoms when first diagnosed. And a person with Type 1 diabetes may have these symptoms anytime he or she stops taking insulin.

Type 2 Diabetes

The most common form (90%) of diabetes mellitus is Type 2. Those with Type 2 diabetes may or may not need to take insulin injections. Often Type 2 diabetes can be controlled with diet, weight loss, exercise, and oral medications. Type 2 diabetes is also known as non-insulin dependent diabetes mellitus (NIDDM) in those who do not require insulin. Unlike Type 1 diabetes, Type 2 is not an autoimmune disorder, though the immune system and genetics may play a role in its development and progression.

The major problem with Type 2 diabetes is not lack of insulin, but rather insulin resistance. Insulin resistance means the cells of the body are not able to use insulin effectively. The insulin levels in Type 2 diabetics may be decreased, normal, or increased, but they are usually increased. Insulin resistance, and the severity of the diabetes, is markedly increased by obesity and lack of exercise.

The oral medications that many Type 2 diabetics take to control blood glucose work in one of two ways. Either they increase the amount of insulin that the pancreas is able to secrete. Or they improve the ability of the cells to use insulin thereby reducing insulin resistance. Studies have shown that exercise can decrease insulin resistance as much as oral medication.

Historically, Type 2 diabetes developed slowly over a period of years, and a person did not need to take insulin until he or she had the disease for a while. Type 2 diabetes has been known as “adult-onset diabetes mellitus” or “maturity-onset diabetes mellitus,” because it usually developed after age 40. Now in the U.S. even children are developing Type 2 diabetes. Onset at earlier ages is occurring because of increasing childhood obesity, lack of exercise, and access to high-fat junk food. The wave of Type 2 diabetes has not yet reached a peak, as the effects of the child obesity epidemic have not had time to fully develop, and the adult population continues to become increasingly obese. Increasing numbers of claims for Social Security disability benefits based on diabetes can be expected.

Other Types of Diabetes

A few cases of diabetes mellitus are not Type 1 or 2. Gestational diabetes appears during pregnancy. The problem arises from a combination of insufficient insulin and the effects of hormonal changes associated with pregnancy. After pregnancy, the diabetes will usually abate, but 5% to 10% of gestational diabetes cases are actually Type 2 diabetics. A person with gestational diabetes has an increased risk for eventual development of diabetes, even if the gestational diabetes resolves. Various medical problems like surgery, malnutrition, infection, pancreatic trauma, and drugs can be enough to push a person over into diabetes and account for about 1% to 5% of all diabetics.

Diagnosis of Diabetes Mellitus

Diabetes is diagnosed when blood sugar (glucose) levels are high. Medical authorities disagree about how high glucose levels must be for the diagnosis. Normal fasting blood glucose (FBG) levels are no higher than 110 mg% (110 mg/dL); some authorities put the upper limit of normal at 115 mg%. It is generally agreed that a FBG of 140 mg/dL or greater on at least two separate days should be considered diagnostic of diabetes mellitus in anyone. This threshold is the “gold standard” for diagnosing diabetes.

The American Diabetes Association (ADA) has lower plasma glucose thresholds for diagnosing diabetes. The criteria for the diagnosis of diabetes mellitus according to the recommendations of the American Diabetes Association are:

• Random (casual) plasma glucose level over 200 mg/dL in the presence of symptoms of diabetes (the classic symptoms including excessive urination, excessive thirst, and unexplained weight loss);

Or

• A fasting plasma glucose level over 126 mg/dL;

Or

• An oral glucose tolerance test with a two hour post-load plasma glucose level over 200 mg/dL.

To establish the diagnosis of diabetes mellitus, according to the ADA, any of the above three tests must be done at least twice and on different days. However, not all endocrinologists subscribe to the ADA diagnostic criteria.

Some individuals are diagnosed as having “pre-diabetes.” The diagnosis is based on glucose levels that are higher than normal, but below the thresholds for diagnosing diabetes. Millions of Americans are pre-diabetic and have increased risk of strokes, peripheral vascular disease, heart attacks, and diabetes.

Ketoacidosis

Ketoacidosis is a serious condition that can occur in people with Type 1 diabetes. You may meet the diabetes listing and be eligible for social security disability benefits if you have episodes of ketoacidosis one every two months on average. See Meeting Listing 9.08B for Diabetes.

It results when insulin levels approach zero. It is called ketoacidosis because compounds called ketones are released into the blood and secreted in the urine and breath and the ph of the blood becomes lower than normal making it acidic. Symptoms of ketoacidosis include dehydration, weight loss, mental confusion, nausea and vomiting, rapid and deep breathing, and, if untreated, unconsciousness, coma, and death.

Ketoacidosis develops in the following way. When insulin levels are very low, the cells are starved for glucose, even though glucose is in the blood stream. In an attempt to compensate for the apparent lack of glucose, the pancreas releases the hormone glucagon. Glucagon causes the liver to convert sugar it has stored as glycogen to glucose. This additional glucose increases blood sugar levels even more, leading to a condition known as hyperglycemia. Hyperglycemia results because only the brain can use the large amounts of glucose being produced. Other tissues cannot use the glucose without insulin. Since the cells have no usable energy source, the body begins to break down fat for energy. As part of the fat metabolism process, the liver releases chemicals known as ketones into the blood stream. These ketones increase the acidity of the blood, so that the pH drops below its normal range of 7.35–7.45.

The decrease in pH in acidosis can be measured with an arterial blood gas study (ABGS). In addition to the decrease in pH, ketoacidosis on ABGS will show a decrease in bicarbonate (strongCO3), a normal value being about 21–28 meq/L. Decreased carbon dioxide gas pressure (pCO2) will be present, normal PaCO2 being about 35–45 mm Hg.

Ketoacidosis can be confirmed by the detection of acetone or acetoacetate in blood or urine. Dipsticks can be used for urine, so more formal laboratory tests are not necessarily required. There are also other forms of testing (e.g., Acetest tablets).

People with Type 2 diabetes rarely experience ketoacidosis. The reason for this is unclear, since they can have severe hyperglycemia and in some instances require insulin.

Complications of Diabetes

Diabetes is a terrible disease that can affect all tissues in the body. The major types of severe organ damage caused by diabetes mellitus are:

Neuropathy (nerve damage)

Diabetes commonly produces progressive damage in peripheral nerves (the nerves outside the brain and spinal cord). The damage often leads to numbness in the feet and legs. This is called sensory peripheral neuropathy and is the most common type of neuropathy (see Figure 1 below). If you have diabetic neuropathy, you may meet qualify for Social Security disability benefits by meeting a listing. See Meeting Social Security Administration Listing 9.08A for Diabetes.

Diabetic sensory peripheral neuropathy can also result in a lack of position sense (proprioception) in the legs, so that the diabetic has difficulty balancing and walking normally. Diabetes may also produce a motor peripheral neuropathy. This means the motor nerves that activate muscles can be damaged causes the muscles to be weak. Nerve conduction studies (NCS) can objectively measure the severity of peripheral neuropathy. A second type of neuropathy common to diabetics is autonomic neuropathy (see Figure 2 below). Inautonomic neuropathy, autonomic nerves (nerves that regulate involuntary body functions) are damaged. For example, damage may occur to cardiac nerves that help regulate heart rhythm, gastric nerves that move the stomach walls, or nerves in the walls of arteries that help adjust vessel diameter to maintain blood pressure with body position changes. After peripheral or autonomic neuropathy has occurred, it does not necessarily improve—especially if it is advanced. Furthermore, a person’s blood glucose may normalize with treatment and his or her nerve conduction velocity values may then return to normal, but the individual may still experience the symptoms of peripheral neuropathy. The Social Security Administration should not presume that a claimant with neuropathy that does not improve as documented by the treating physician’s examination is not credible on the basis of an improved NCS alone.

NCS cannot be done for autonomic neuropathy since those nerves are not normally accessible.

Figures 1 and 2: Sensory peripheral neuropathy (top) and autonomic neuropathy bottom.

Diabetic Retinopathy

Diabetic retinopathyis one of the most frequent causes of blindness in the U.S., and the Social Security Administration sees many such claimants. If your diabetic retinopathy is severe, you may qualify for Social Security disability benefits by meeting a listing. See Meeting Listing 9.08C for Diabetes.

Kidney Failure

One of the major causes of kidney failure in the U.S. is diabetes mellitus.

Heart Disease

Diabetes is a major contributor to the development of coronary artery disease and peripheral vascular arterial disease, as well as additional complications such as heart failure.

Amputation

Diabetes is a major cause of the need for amputation of lower extremities. This complication occurs because the diabetes compromises immunity and resistance to bacterial infection, and because diabetes decreases blood flow in small arterial vessels. These facts mean a person can develop an infection from a minor injury to the foot when trimming the toenails. Infection is difficult to control when blood flow is compromised and immunity impaired; antibiotics may not be effective. Tissue death (gangrene) may require amputation, and sometimes repeated amputations.

Stroke

Because of vascular damage, people with diabetes have a high rate of strokes. See Can I Get Social Security Disability Benefits After a Stroke?

High Blood Sugar and Diabetic Complications

Whether in Type 1 or 2 diabetes mellitus, high blood sugar or hyperglycemia has relentless destructive effects on most major body systems. Regulation of blood glucose levels with insulin, or other treatment is known as “control.” In general, tighter control of blood glucose with insulin injections, or medication, and diet and exercise, means better control of complications. But good control will not necessarily reverse damage that has already been done, although improvement may be possible. Other factors are in play besides blood glucose control, because good control does not necessarily stop progression of a diabetic complication once damage has been done. However, good glucose control will slow the progression.

Good glucose control is difficult to achieve because there is currently no way to deliver insulin or other glucose-controlling drugs with the same degree of precision as a normal human body. Pancreatic transplantation can be beneficial to patients with severe complications and difficult to control diabetes, but this is not a solution for most in view of possible complications with the transplant itself. Understandably, people do not like having to inject themselves with insulin. Insulin pumps have been in existence for some years. More recent experimental innovations have been inhaled insulin and insulin patches.

Some diabetics have higher glucose levels due to poor compliance with treatment; when non-compliance is an issue, it will usually be noted in the treating physician’s medical records. Obvious intentional non-compliance leading to severe hyperglycemia and hospitalization seems to be more of a problem with some teenagers than adults. In other instances, a diabetic may have insufficient money for medication, or have a mental disorder like major depression, schizophrenia, or mental retardation. Some claimants who have to inject insulin have difficulty seeing well enough to draw up the proper dose of insulin.

Hard to Control or Brittle Diabetes

Some cases of diabetes are difficult to control even though the patient carefully follows the prescribed treatment. These are cases of brittle diabetes in which the blood glucose levels vary widely and constant adjustments have to be made in insulin doses. The Social Security Administration should take into account the presence of brittle diabetes, but this is difficult to do if the treating doctor’s records are inadequate. Difficult to control diabetes tends to occur when insulin levels fall to zero, because there is no natural insulin to help cushion swings in blood glucose. Poor compliance with treatment and highly variable emotional states can contribute to difficult control; emotions influence the levels of hormones that affect the regulation of blood glucose. However, this subject is not fully understood. See Brittle Diabetes and Residual Functional Capacity.

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

Can I Get Social Security Disability Benefits After a Stroke?

• How Does the Social Security Administration Determine if I Qualify for Disability Benefits for a Stroke?
• About Stroke and Disability
• Winning Social Security Disability Benefits for Stroke by Meeting a Listing
• Residual Functional Capacity Assessment for Stroke
• Getting Your Doctor’s Medical Opinion

How Does the Social Security Administration Determine if I Qualify for Disability Benefits for a Stroke?

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

About Stroke and Disability

What Is a Stroke?

A stroke is called a cerebrovascular accident or CVA by medical professionals. It is usually caused by either:

• Blockage of an artery in the brain by a blood clot or fatty deposits, which is called a cerebral infarction;

OR

• A ruptured cerebral artery bleeding into the brain, which is called a cerebral hemorrhage.

Some strokes are caused by cerebral aneurysms.

The Social Security Administration sees large numbers of stroke cases.

Strokes Caused by Blockage of an Artery

Most strokes are caused by cerebral infarction in which an artery in the brain (see Figures 1 and 2 below) is blocked depriving the brain of blood and damaging brain tissue. An arterial thrombosis (blood clot) is the most common cause of cerebral infarction. Such a clot could form in a cerebral artery itself or in the heart as a result of a variety of heart problems and be pumped to the brain. Blockage of a cerebral artery by the fatty deposits of atherosclerosis can also deprive an area of the brain of blood and lead to infarction. Actually, many cerebral infarctions are caused by cerebrovascular disease in which a blood clot forms around fatty plaques. Unlike arteries in the heart or legs, cerebral arteries cannot be cleaned out of fatty blockages. However, if a stroke occurs as a result of a blood clot, brain damage can be lessened by clot-dissolving drugs. Medical attention must be sought within a few hours for treatment to be effective and clot-dissolving drugs pose some risk of causing deadly bleeding.

A piece of atherosclerotic plaque can break off inside one of the two internal carotid arteries in the neck, be pumped to the brain, and lodge in a cerebral artery to cause an infarction.

Figure 1: Veins of the brain.

Figure 2: Base of the brain, including main arteries.

Strokes Caused by Ruptured Cerebral Artery (Cerebral Hemorrhage)

The most frequent cause of hemorrhagic CVAs is uncontrolled hypertension (high blood pressure), often related to non-compliance with medical treatment. The Social Security Administration sees many such tragic cases. Bleeding in the brain may also occur from abnormal tangles of blood vessel growths called vascular malformations and cerebral aneurysms.

Strokes Caused by Cerebral Aneurysms

Incidence of Cerebral Aneurysms

A significant number of strokes are caused by cerebral aneurysms, which are enlarged, and weak areas of a cerebral artery that can rupture and cause a subarachnoid hemorrhage (SAH). Aneurysms in the cerebral circulation are common. They are estimated to occur in between 1% and 5% of the general population and account for 5% to 15% of strokes. The most common location for cerebral aneurysms is the anterior cerebral artery. Cerebral aneurysms are twice as common in women as in men. They occur more frequently in individuals with certain disorders such as autosomal dominant polycystic kidney disease. More than one aneurysm may be present.

Millions of Americans have cerebral aneurysms. Although somewhere between 50% to 80% of aneurysms are small and do not rupture—many are only found incidentally at autopsy—that still leaves millions of individuals at risk for death or debilitating stroke.

Effects of Rupture

If a stroke occurs, the prognosis is grave, with a mortality of about 40% to 50% within 30 days of the first rupture. For surviving patients with SAH, about 30% have significant neurological abnormalities. For instance, following SAH, 15% to 20% of individuals will develop hydrocephalus (fluid accumulation on the brain) and require further neurosurgical procedures to treat that serious brain disorder.

The following scale is widely used by physicians to describe a patient’s condition after SAH:

Re-bleeding Risk

If a person has experienced one rupture (bleeding episode) from an aneurysm, the risk of future bleeding is increased to 10 times that of someone with a no rupture history. If the aneurysm was large (10 mm or more), the risk of rebleeding is even higher.

If an aneurysm has not bled previously, data indicates a low bleeding risk of 0.05% per year; in aneurysms less than 7 mm, the 5-year risk approaches zero in the absence of a bleeding history. However, the size of an aneurysm is not the only consideration—aneurysms putting pressure on vital brain structures, such as a cranial nerve (see Figure 3 below), require surgical intervention at a smaller size.

Figure 3: Cranial nerves at the base of the brain.

Diagnosis and Surgical Treatment of Cerebral Aneurysms

Many unruptured cerebral aneurysms can now be identified with CTA or MRA, without the more invasive catheter angiography. However, catheter angiography better diagnoses SAH. Angiography of any type is not perfect and can fail to identify small aneurysms of less than 3 mm.

Cerebral aneurysms may be treated surgically to reduce the risk of rupture, rebleeding, or brain damage from pressure the aneurysm places on brain tissue. Surgery to place a metal clip on the neck of an aneurysm that connects it to a parent vessel has been the standard treatment in the past. This procedure is major brain surgery and requires a craniotomy. A piece of the skull (skull flap) is sawed under general anesthesia and laid back for entry into the brain. This surgery has risks and the surgical risks for small aneurysms considerably exceed the risks of conservative (non-surgical) treatment.

A second surgical option has been the use of detachable coils of various sizes and shapes, which can be inserted without opening the skull. These coils are advanced by microcatheter to the aneurysm through the femoral artery in the leg, and then up through the carotid artery in the neck into the cerebral circulation. The coil is then detached inside the aneurysm to block blood flow through the neck of the aneurysm into its main body. Thus, the patient is spared the very invasive craniotomy. Although the risk of rebleeding after coiling is slightly greater than after clipping, the safety of coiling appears greater in many instances. Medical judgment in individual cases is still required to determine the best treatment option, but it is likely that coiling will continue to replace a significant number of cases that would otherwise have required clipping.

Diagnosis of Stroke

Evidence that a CVA has occurred is based on history and physical examination, as well as neuroimaging with computerized tomographic angiography (CTA) or magnetic resonance angiography (MRA) of the brain. Cerebral catheter angiography, a much older procedure than CTA or MRA, is still sometimes used. It carries some risk and is not needed to evaluate most CVAs. Cerebral catheter angiography involves direct injection of x-ray contrast material to outline the arteries of the brain. A catheter is threaded through the femoral artery in the leg, up into a carotid artery in the neck, and then manipulated into the cerebral circulation where contrast injection takes place.

Recovery from Stroke

Brain cells that are killed by a stroke are not replaced with new cells. The brain cannot re-grow any part of itself. But it can re-arrange brain cell connections to some degree to compensate for injury. The ability of the brain to compensate for injury decreases with age. Recovery from stroke depends on the ability of remaining brain areas to perform necessary functions, and recovery of areas not permanently damaged by the CVA. Rehabilitation is very important in achieving maximum possible recovery, and should be instituted as soon as possible after the CVA.

Effects of Stoke

CVAs can be of all degrees of severity, and the type of damage they do depends on where in the brain they occur. Some CVAs cause death immediately, while others may cause little limitation. There might be good recovery, or very little.

Strokes can have many effects depending on what areas of the brain are damaged (see Figure 4 below):

• Weakness, paralysis, numbness. Most CVA claimants are awarded disability benefits because of limitations in movement or motor ability, such as weakness and paralysis in an arm and leg on the same side of the body as a result of blockage (occlusion) in the middle cerebral artery or one of its branches.
• Speech and language problems. Strokes sometimes produce some degree of loss of ability to understand or express certain aspects of written or spoken language in various combinations (known as aphasia).
• Personality changes. A CVA far forward (anterior) in a frontal lobe might produce personality changes if it is large enough, without any physical limitations.
• Vision problems. A CVA might involve the occipital lobes in the back of the brain. The occipital lobes process primary visual information and a stroke in that area would produce visual losses either in acuity (sharpness) or visual fields (how wide an area a person can see) without any other impairment. Major strokes that are not in the occipital lobes may result in visual field losses in the form of loss of half of the person’s visual field. Each half of the brain carries half the total visual information. Most CVAs only involve one side of the brain and therefore at the worst can only eliminate half of a person’s visual field in a pattern called homonymous hemianopsia0.
• Balance problems. Strokes affecting the parietal lobes of the brain can produce distortions in the mental construction of space and cause loss of an awareness of body parts, a condition known as unilateral neglect. It is important that the neurological examination of a patient after a CVA detect unilateral neglect, because non-awareness of a limb makes it as functionally useless as paralysis. Strokes affecting the posterior circulation to the cerebellum can affect balance and ability to walk without producing any actual weakness.

Figure 4: The Circle of Willis, showing main cerebral arteries and the parts of the brain they supply.

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