SSR 03-01p: SSR 03-1p: Titles II and XVI: Development and Evaluation of Disability Claims Involving Postpolio Sequelae

[Federal Register: July 2, 2003 (Volume 68, Number 127)] [Notices] [Page 39611-39614] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr02jy03-144]

EFFECTIVE DATE: July 2, 2003

Policy Interpretation Ruling

Purpose:

To provide guidance on SSA policy concerning the

development and evaluation of postpolio sequelae in disability claims

filed under titles II and XVI of the Social Security Act (the Act).

Citations (Authority):

Sections 216(i) , 223(d) , 223(f) , 1614(a)(3) and 1614(a)(4) of

the Social Security Act, as amended; Regulations No. 4, subpart P,

sections 404.1502 , 404.1505 , 404.1508 , 404.1509 , 404.1511 - 404.1513 , 404.1520 , 404.1520a , 404.1521 , 404.1523 , 404.1525 , 404.1526 , 404.1528 , 404.1529 , 404.1530 , 404.1545 , 404.1546 , 404.1560 - 404.1569a ;

and 404.1593 - 404.1594 and Regulations No. 16, subpart I, sections 416.902 , 416.905 , 416.906 , 416.908 , 416.909 , 416.911 , 416.913 , 416.920 , 416.920a , 416.921 , 416.923 , 416.924 , 416.924a -416.924c, 416.925 , 416.926 , 416.926a , 416.928 , 416.929 , 416.930 , 416.945 , 416.946 , 416.960 - 416.969a , 416.987 , and 416.993 - 416.994a .

Introduction:

“Postpolio sequelae” refers to the documented

residuals of acute polioencephalomyelitis (polio) [1] infection as well

as other disorders that have an etiological link to either the acute

polio infection or to chronic deficits resulting from the acute

infection. Disorders that may manifest late in the lives of polio

survivors include postpolio syndrome (also known as the late effects of

poliomyelitis), early advanced degenerative arthritis, sleep disorders,

respiratory insufficiency, and a variety of mental disorders. Any one

or a combination of these disorders, appropriately documented, will

constitute the presence of “postpolio sequelae” for purposes of

developing and evaluating claims for disability on the basis of

postpolio sequelae under Social Security disability

s of

poliomyelitis), early advanced degenerative arthritis, sleep disorders,

respiratory insufficiency, and a variety of mental disorders. Any one

or a combination of these disorders, appropriately documented, will

constitute the presence of “postpolio sequelae” for purposes of

developing and evaluating claims for disability on the basis of

postpolio sequelae under Social Security disability. Even though some

polio survivors may have had previously undetected motor residuals

following the acute polio infection, they may still report progressive

muscle weakness later in life and manifest any of the disorders listed

above.

The Act and our implementing regulations require that an individual

establish disability based on the existence of a medically determinable

impairment; i.e., one that can be shown by medical evidence, consisting

of symptoms, signs, and laboratory findings. Disability may not be

established on the basis of an individual's statement of symptoms

alone.

This Ruling explains that postpolio sequelae, when accompanied by

appropriate symptoms, signs, and laboratory findings, is a medically

determinable impairment that can be the basis for a finding of

“disability.” It also provides guidance for the evaluation

of claims involving postpolio sequelae.

Policy Interpretation:

Postpolio sequelae constitute a medically determinable impairment when

documented by appropriate medical signs, symptoms, and laboratory

findings. Postpolio sequelae may be the basis for a finding of

“disability,” as discussed below. When making a determination of

disability in cases of postpolio sequelae, the adjudicator or

decisionmaker must be sure that all of the individual's functional

limitations have been considered. To do this, the adjudicator must make

a comprehensive assessment of the cumulative and interactive effects of

all of the individual's impairments and related symptoms, including the

effects of postpolio sequelae.

What Is the Definition of “Disability” and

“Medically Determinable Impairment”?

r or

decisionmaker must be sure that all of the individual's functional

limitations have been considered. To do this, the adjudicator must make

a comprehensive assessment of the cumulative and interactive effects of

all of the individual's impairments and related symptoms, including the

effects of postpolio sequelae.

What Is the Definition of “Disability” and

“Medically Determinable Impairment”?

Sections 216(i) and 1614(a)(3) of

the Social Security Act (the Act)

define “disability” [2] as the inability to engage in any substantial

gainful activity (SGA) by reason of any medically determinable physical

or mental impairment (or combination of impairments) which can be

expected to result in death or which has lasted or can be expected to

last a continuous period of not less than 12 months. Sections 223(d)(3) and 1614(a)(3)(D) of the Act, and 20 CFR 404.1508 and 416.908 , require

that an impairment result from anatomical, physiological, or

psychological abnormalities that can be shown by medically acceptable

clinical and laboratory diagnostic techniques. The Act and regulations

further require that an impairment be established by medical evidence

that consists of signs, symptoms, and laboratory findings, and not only

by an individual's statement of symptoms.

For Purposes of Disability Claims Adjudication, What Constitutes

Postpolio Sequelae?

For purposes of disability claims adjudication, postpolio sequelae

refer to multiple physical and mental disorders that may be manifested

by polio survivors many years following acute polio infection. Any one

or a combination of these disorders appropriately documented by signs,

symptoms, and laboratory findings will constitute the presence of

postpolio sequelae. The term “postpolio sequelae” includes the

documented residuals of acute infection as well as all other documented

clinical conditions that have an etiological link to either the acute

infection or to its residual deficits.

tion. Any one

or a combination of these disorders appropriately documented by signs,

symptoms, and laboratory findings will constitute the presence of

postpolio sequelae. The term “postpolio sequelae” includes the

documented residuals of acute infection as well as all other documented

clinical conditions that have an etiological link to either the acute

infection or to its residual deficits.

Motor weakness is the most common residual of acute polio infection

and is usually manifested by observable weakness, muscle atrophy, and

reduced peripheral reflexes. These obvious clinical findings are used

to document the history of poliomyelitis.

Electromyographic studies may be used by clinicians in clarifying

the cause and extent of neuromuscular impairment, but should not be

needed for purposes of disability decisionmaking. Nonetheless, when

electromyography (EMG) results are available for review, these data

should be considered in decisionmaking. Typically, we will not order or

purchase EMG studies.

In the absence of evidence to the contrary, and as long as the

medical findings support a reasonable medical link between the prior

polio infection and the present manifestation of any one or combination

of the disorders discussed in the ruling, we will find that the

individual has postpolio sequelae. For example, an individual with a

history of polio affecting the left lower extremity who, on

examination, has weakness and atrophy of the left thigh musculature

with an observable limp now complains of chronic left lower extremity

pain and is found to have lumbar stenosis documented by medically

acceptable imaging. As discussed below, due to the chronic postural

imbalance related to the effects of polio, a reasonable medical link

exists between this individual's current medical condition

(degenerative lumbar spine disease) and his/her prior polio residuals.

Accordingly, we would make a finding of postpolio sequelae

ty

pain and is found to have lumbar stenosis documented by medically

acceptable imaging. As discussed below, due to the chronic postural

imbalance related to the effects of polio, a reasonable medical link

exists between this individual's current medical condition

(degenerative lumbar spine disease) and his/her prior polio residuals.

Accordingly, we would make a finding of postpolio sequelae. On the

other hand, an individual with a history of polio (for example, stating

“I was in an iron lung”) who, on examination, has normal motor

findings, including normal posture and gait, now complains of pain

clinically consistent with chronic radiculopathy, and has medically

acceptable imaging demonstrating degenerative arthritis in the lumbar

spine. This individual's current medical condition does not demonstrate

a reasonable medical connection with the prior polio; instead, the

degenerative arthritis should be adjudicated as a musculoskeletal

disorder unrelated to the prior polio infection.

Postpolio sequelae include such disorders as postpolio syndrome

(also know as the late effects of poliomyelitis), early advanced

degenerative arthritis, sleep disorders, respiratory insufficiency, and

various mental disorders. These disorders and documentation issues

concerning them are discussed in detail below.

What Is Meant by the Term “Postpolio Syndrome”?

According to the National Institute of Neurological Disorders and

Stroke (NINDS), postpolio syndrome is a condition that affects polio

survivors anywhere from 10 to 40 years after recovery from an initial

paralytic attack of the poliomyelitis virus. The NINDS states that

postpolio syndrome is characterized by a further weakening of muscles

that were previously affected by the polio infection. The signs and

symptoms include fatigue, slowly progressive muscle weakness, and, at

times, muscular atrophy. The NINDS states that joint pain and

increasing skeletal deformities such as scoliosis are common

ralytic attack of the poliomyelitis virus. The NINDS states that

postpolio syndrome is characterized by a further weakening of muscles

that were previously affected by the polio infection. The signs and

symptoms include fatigue, slowly progressive muscle weakness, and, at

times, muscular atrophy. The NINDS states that joint pain and

increasing skeletal deformities such as scoliosis are common. Not all

polio survivors experience these clinical problems, and the extent to

which polio survivors are affected by postpolio syndrome varies. The

onset of new or worsening signs and symptoms is associated with a

further reduction of the individual's capacity to independently carry

out activities of daily living.

How Does the Presence of Early Advanced Degenerative Arthritis

Constitute an Element of Postpolio Sequelae?

Polio survivors often manifest motor residuals in a single

extremity and thus function day-to-day with chronic postural imbalance.

Clinicians have described degenerative musculoskeletal disorders

etiologically linked to long-standing postural imbalance. Abnormal

weight-bearing in polio survivors produces exaggerated wear and tear on

the bones and joints of the spine or limbs that are overused to

compensate for limbs weakened by polio. Early onset of advanced

degenerative arthritis can be found in a compensatory extremity or

spine. Where such an etiological relationship is clear, clinically

documented early advanced degenerative arthritis in a compensating limb

or spine is considered one of the postpolio sequelae.

Documentation of early advanced degenerative arthritis may include

medically appropriate imaging or abnormal physical findings of advanced

arthritis on clinical examination.

Chronic pain disorders related to early degenerative osteoarthritis

should be evaluated based on the impact of the pain and its treatment

on the individual's physical and mental functioning.

Why Are Sleep Disorders and Respiratory Insufficiency Possible

Manifestations of Postpolio Sequelae?

cally appropriate imaging or abnormal physical findings of advanced

arthritis on clinical examination.

Chronic pain disorders related to early degenerative osteoarthritis

should be evaluated based on the impact of the pain and its treatment

on the individual's physical and mental functioning.

Why Are Sleep Disorders and Respiratory Insufficiency Possible

Manifestations of Postpolio Sequelae?

Some polio survivors report the occurrence of sleep disorders that are

determined by clinical evaluation to be related to respiratory

insufficiency during sleep. The poliovirus has demonstrated a

propensity to attack the motor neurons responsible for respiratory

function, and, during the acute infection, some individuals require

ventilatory assistance. For example, years ago patients with acute

polio infection were placed in an “iron lung” for ventilatory

assistance. Some patients who required such assistance recovered and

may have returned to normal lives without obvious signs of respiratory

insufficiency. Some polio survivors, however, have reported the onset

of sleep disorders years following the acute polio infection, and

physicians have linked these sleep disorders to weakening of the

respiratory musculature. During sleep, even slight weakness of the

respiratory musculature may become clinically significant and interfere

with breathing capacity. Chronic sleep deprivation resulting from

repeated episodes of sleep apnea may result in the development of

excessive daytime drowsiness or cognitive and behavioral changes.

hysicians have linked these sleep disorders to weakening of the

respiratory musculature. During sleep, even slight weakness of the

respiratory musculature may become clinically significant and interfere

with breathing capacity. Chronic sleep deprivation resulting from

repeated episodes of sleep apnea may result in the development of

excessive daytime drowsiness or cognitive and behavioral changes.

Respiratory insufficiency should be documented by abnormal pulmonary

function studies. The presence of a sleep disorder related to

respiratory insufficiency requires documentation by longitudinal

treatment records, including such things as abnormal polysomnography or

other appropriate evidence. Note, however, that we [3] generally will

not purchase a polysomnogram (also called a PSG, sleep study, or sleep

test). See also 3.00H of the Respiratory System medical listings for

additional information concerning sleep-related breathing disorders

( see 20 CFR appendix 1 to subpart P of part 404—Listing

of Impairments).

What Types of Mental Disorders May Be Seen in Individuals With

Postpolio Sequelae?

Some polio survivors report the onset of problems with attention,

concentration, cognition, or behavior. Some researchers have suggested

that certain cognitive and behavioral deficits are the result of the

prior polio infection that involved the brain, although others do not

agree with that concept. Other researchers have suggested that the

traumatic psychological experiences associated with acute polio

infection are revived when polio survivors recognize the onset of

further weakness and functional loss.

chers have suggested

that certain cognitive and behavioral deficits are the result of the

prior polio infection that involved the brain, although others do not

agree with that concept. Other researchers have suggested that the

traumatic psychological experiences associated with acute polio

infection are revived when polio survivors recognize the onset of

further weakness and functional loss.

Many polio survivors endured a life-threatening infection as young

children. They may have spent extended periods away from their homes

and families while hospitalized with paralysis or respiratory

dysfunction, or while undergoing multiple orthopedic surgeries. Often

they endured many months, or sometimes years, of hospitalization and

rehabilitation. The psychological effect of perceiving the onset of

further weakness, fatigue, respiratory dysfunction or joint pain, many

years following the acute infection, can be significant. Signs and

symptoms of anxiety and depression may produce further deterioration in

function.

Any mental impairment that could have an etiological link to the

acute polio infection or its chronic residuals may be considered a

manifestation of postpolio sequelae. Deficits in attention, cognition,

or behavior may be demonstrated by reduced concentration capacity,

inability to persist in tasks, or memory problems. Also, behavioral

abnormalities may be demonstrated by mood changes, social withdrawal,

or other behaviors inappropriate for the individual. Mood disorders

characterized by anxiety and depression may also be seen and clinically

documented in these individuals.

How Do Postpolio Sequelae Affect an Individual's Functional

Capacities?

capacity,

inability to persist in tasks, or memory problems. Also, behavioral

abnormalities may be demonstrated by mood changes, social withdrawal,

or other behaviors inappropriate for the individual. Mood disorders

characterized by anxiety and depression may also be seen and clinically

documented in these individuals.

How Do Postpolio Sequelae Affect an Individual's Functional

Capacities?

Individuals experiencing postpolio sequelae may complain of the new

onset of reduced physical and mental functional ability. Complaints of

fatigue, weakness, intolerance to cold, joint and muscle pain,

shortness of breath and sleep problems, mood changes, or decreased

attention and concentration capacity may hallmark the onset of

postpolio sequelae. Weakness, fatigue, or muscle and joint pain may

cause increasing problems in activities such as lifting, bending,

prolonged standing, walking, climbing stairs, using a wheelchair,

transferring from a wheelchair (e.g., from wheelchair to toilet),

sleeping, dressing, and any activity that requires repetition or

endurance. Changes in attention, cognition, or behavior may be

manifested by reduced capacity to concentrate on tasks, memory

deficits, mood changes, social withdrawal, or inappropriate behavior.

Many polio survivors who had been in a stable condition may begin

to require new or additional assistive devices, such as braces, canes,

crutches, walkers, wheelchairs, or pulmonary support. The reduced

ability to sustain customary activities, including work, may result. A

previously stable functional capacity may be further diminished.

d changes, social withdrawal, or inappropriate behavior.

Many polio survivors who had been in a stable condition may begin

to require new or additional assistive devices, such as braces, canes,

crutches, walkers, wheelchairs, or pulmonary support. The reduced

ability to sustain customary activities, including work, may result. A

previously stable functional capacity may be further diminished.

Many individuals with medically severe polio residuals have worked

despite their limitations. The new onset of further physical or mental

impairments (even though they may appear to be relatively minor) in

polio survivors may result in further functional problems that can

limit or prevent their ability to continue work activity. Postpolio

sequelae may effectively alter the ability of these individuals to

continue functioning at the same level they maintained for years

following their initial polio infection.

How Will We Document Claims Involving Postpolio Sequelae?

We generally will rely on documentation provided by the

individual's treating physicians and psychologists (including a report

of the medical history, physical examination, and available laboratory

findings) to establish the presence of postpolio sequelae as a

medically determinable impairment. In the absence of evidence to the

contrary, we will make a finding that a medically determinable

impairment is established if any of the disorders discussed above have

been documented by acceptable clinical signs, symptoms, and laboratory

findings.

However, if evidence indicates that the diagnosis is questionable,

we will contact the treating source for clarification, in accordance

with 20 CFR 404.1512(e) and 416.912(e) . Of course,

if a favorable

disability determination or decision can be made based on the available

evidence of record, whether or not a link to the prior polio infection

is evident, no further development need be undertaken.

r, if evidence indicates that the diagnosis is questionable,

we will contact the treating source for clarification, in accordance

with 20 CFR 404.1512(e) and 416.912(e) . Of course,

if a favorable

disability determination or decision can be made based on the available

evidence of record, whether or not a link to the prior polio infection

is evident, no further development need be undertaken.

The careful development of postpolio sequelae should include

descriptions of the past acute illness (old records are not required),

as well as a report of the current findings on physical examination.

The examination report should also include the severity of any residual

weakness, as well as the onset, pattern, and severity of any new

physical or mental deficits. A description of current functional

limitations and restrictions on physical and mental activity should be

obtained from the examiner.

When possible, detailed longitudinal treatment records from the

treating source should be obtained. In cases where severity of the

impairment is unclear, an examination by a physician or psychologist

who is knowledgeable about polio and postpolio sequelae is appropriate,

if such a specialist is available.

How Will We Use Evidence From Third Parties in Cases of Postpolio

Sequelae?

Evidence from employers and other third party sources may be

valuable in documenting a loss of a previous level of functioning and

should be sought when there is a discrepancy or a question of

credibility in the evidence of record and a fully favorable

determination or decision cannot be made based on the available

evidence. For detailed discussions regarding these factors, please

refer to SSR 96-7p ,

“Titles II and XVI: Evaluation of Symptoms in

Disability Claims: Assessing the Credibility of an Individual's

Statements,” and SSR 96-8p ,

“Titles II and XVI: Assessing the

Residual Functional Capacity (RFC) in Initial Claims.”

How Are Symptoms Assessed in Cases of Postpolio Sequelae?

d on the available

evidence. For detailed discussions regarding these factors, please

refer to SSR 96-7p ,

“Titles II and XVI: Evaluation of Symptoms in

Disability Claims: Assessing the Credibility of an Individual's

Statements,” and SSR 96-8p ,

“Titles II and XVI: Assessing the

Residual Functional Capacity (RFC) in Initial Claims.”

How Are Symptoms Assessed in Cases of Postpolio Sequelae?

Once postpolio sequelae has been documented as a medically

determinable impairment, the impact of any of the symptoms of postpolio

sequelae, including fatigue, weakness, pain, intolerance to cold, etc.,

must be considered both in determining the severity of the impairment

and in assessing the individual's RFC. The adjudicator must make a

comprehensive assessment of the cumulative and interactive effects of

all of the individual's impairments and related symptoms, including the

effects of postpolio sequelae. Evaluate all symptoms and their effects

in accordance with 20 CFR 404.1529 and 416.929 , and SSR 96-7p , “Titles

II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the

Credibility of an Individual's Statements.”

What Is the Expected Duration of Postpolio Sequelae?

Most postpolio sequelae are stable or very slowly progressive

disorders. The medical evidence should readily support an expected

duration of at least 12 or more months.

Can the Impairment of Postpolio Sequelae Meet or Equal

Listing 11.11?

valuation of Symptoms in Disability Claims: Assessing the

Credibility of an Individual's Statements.”

What Is the Expected Duration of Postpolio Sequelae?

Most postpolio sequelae are stable or very slowly progressive

disorders. The medical evidence should readily support an expected

duration of at least 12 or more months.

Can the Impairment of Postpolio Sequelae Meet or Equal

Listing 11.11?

The listing criteria under our current listing 11.11, Anterior

poliomyelitis, may be applied both to cases of static polio (where

there has been no reported worsening after initial recovery) and to

cases presenting with postpolio sequelae. All documented postpolio

sequelae must be considered either alone or in combination to determine

whether the medical criteria of listing 11.11, or any other listing,

have been met or equaled. If the impairment is not found to meet or

equal a listed impairment, we consider the impact of the impairment and

any related symptoms in determining an individual's RFC and we proceed

to evaluate the individual's impairment under our sequential evaluation

procedures in accordance with 20 CFR 404.1545 and 416.945 . It is

essential that the cumulative and interactive effects of all of the

individual's impairments, including symptoms, be carefully assessed in

determining the individual's RFC in these cases.

How Is a Disability Onset Date Determined in Case of Postpolio

Sequelae?

A disability onset date in cases involving postpolio sequelae is

set based on the individual's allegations, his or her work history, and

the medical and other evidence concerning impairment severity.

Generally, the new problems associated with postpolio sequelae are

gradual and non-traumatic, but acute injuries or events, such as

herniated discs, or broken bones from falls, may be markers for

establishing a disability onset date. For additional discussion

concerning the determination of onset date, refer to SSR 83-20 ,

“Titles II and XVI: Onset of Disability.”

Effective Date:

severity.

Generally, the new problems associated with postpolio sequelae are

gradual and non-traumatic, but acute injuries or events, such as

herniated discs, or broken bones from falls, may be markers for

establishing a disability onset date. For additional discussion

concerning the determination of onset date, refer to SSR 83-20 ,

“Titles II and XVI: Onset of Disability.”

Effective Date:

This ruling is effective upon publication in the Federal Register .

Cross References:

SSR 83-20 ,

“Titles II and XVI: Onset of Disability,” SSR 96-3p ,

“Titles II and XVI: Considering Allegations of Pain and

Other Symptoms in Determining Whether a Medically Determinable

Impairment is Severe,” SSR 96-4p ,

“Titles II and XVI: Symptoms, Medically Determinable Physical and

Mental Impairments, and Exertional and Nonexertional Limitations,” SSR 96-7p ,

“Titles II and XVI: Evaluation of Symptoms in Disability Claims:

Assessing the Credibility of an Individual's Statements,” SSR 96-8p ,

“Titles II and XVI: Assessing Residual Functional Capacity

in Initial Claims,” and SSR 96-9p , “Titles II and XVI:

Determining Capability to Do Other Work—Implications of a Residual

Functional Capacity for Less Than a Full Range of Sedentary Work.”

[1] Polio is caused by one of three types of polioviruses

affecting the brain and spinal cord. No matter which neurons are

attacked by the virus, the severity of any residual deficit depends

upon how many cells within a specific area are destroyed.

Fortunately, the polio infection was eradicated in the United States

during the late 1950s following the development of oral polio

vaccine and successful mass immunization. Most polio survivors in

this country are now in their forties or older, but polio continues

to be a common infection in underdeveloped countries. The World

Health Organization is sponsoring immunization programs in hopes of

completely eradicating the disease

eradicated in the United States

during the late 1950s following the development of oral polio

vaccine and successful mass immunization. Most polio survivors in

this country are now in their forties or older, but polio continues

to be a common infection in underdeveloped countries. The World

Health Organization is sponsoring immunization programs in hopes of

completely eradicating the disease. Most individuals who contract

polio only have mild symptoms at the time of the initial infection

and then fully recover. Only 2 percent of infected persons

experience paralysis from polio. Deaths from acute polio infection

usually occur within the first few days following the onset of

paralysis. About one-third of those individuals who do develop

paralysis are left with some degree of permanent weakness, commonly

involving a single extremity. Postpolio muscle paralysis is of the

lower motor neuron variety and is characterized by weakness, muscle

atrophy, and reflex loss.

[2] Except for statutory blindness.

[3] The terms we and us in this Social Security Ruling have the

same meaning as in 20 CFR 404.1502 and 416.902 . We or us refers to

either the Social Security Administration or the State agency making

the disability or blindness determination; that is, our adjudicators

at all levels of the administrative review process and our quality

reviewers.