Page images
PDF
EPUB

flexion measured from the neutral position and one of the following:

1. Calcification of the anterior and lateral ligaments as shown by X-ray; or

2. Bilateral ankylosis of sacroiliac joints and abnormal apophyseal articulations as shown by X-ray.

1.06 Tuberculosis of the spine or any major joint. Active.

1.07 Nerve root compression syndrome (due to any cause). With:

A. Pain and motion limitation in back or neck; and

B. Cervical or lumbar nerve root compression as evidenced by appropriate radicular distribution of sensory, motor, and reflex abnormalities.

by

1.08 Osteomyelitis (demonstrated X-ray). A. Pelvis, vertebra, femur, tibia or a major joint of an upper or lower extremity, with persistent activity or occurrence of at least 2 episodes in the 6 months since onset of disability manifested by local or systemic signs or laboratory findings (e.g., heat, redness, swelling, drainage, leucocytosis, or increased sedimentation rate); or

B. With multiple localizations and systemic manifestations such as anemia (hematocrit of 30 percent or less) or amyloid changes.

1.09 Amputation of; or anatomical deformity of (i.e., loss of major function due to degenerative changes associated with vascular or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence of bony or fibrous ankylosis at an unfavorable angle, joint subluxation instability). A. Both hands; or

B. Both feet; or

C. One hand and one foot.

or

1.10 Amputation of lower extremity (at or above the tarsal region). A. Hemipelvectomy or hip disarticulation; or

B. Evaluate an amputation associated with peripheral vascular disease or diabetes mellitus under the criteria in § 4.13 or § 9.08; or C. Inability to use prosthesis effectively, without other assistive devices, due to: 1. Vascular disease; or

2. Neurological complications (e.g., loss of position sense); or

3. Stump complications persisting, or expected to persist, for at least 12 months from onset of disability; or

4. Disorder of contralateral lower extremity causing mobility restriction.

1.11 Fracture of femur, tibia, tarsal bone or pelvis. With solid union not evident on X-ray and return to full weight-bearing status did not occur, or is not expected to within 12 months of onset. occur,

1.12 Fractures and/or soft tissue injuries of an upper extremity. A. With non-union of a fracture of the shaft of the humerus, radius, or ulna under continuing surgical management directed toward restoration of functional use of the extremity and such function was not restored or expected to be

restored within 12 months after onset; or

B. Requiring a series of staged surgical procedures within 12 months after onset for salvage and/or restoration of major function of the extremity, and such major function was not restored or expected to be restored within 12 months after onset; or

C. After maximum benefit from surgical therapy has been achieved (1.e., there have been no significant changes in physical findings and/or X-ray findings for any 6-month period after the last definitive surgical procedure), the residual of fractures and/or soft tissue injuries of an upper extremity should be evaluated under the criteria in § 1.09 when associated with residual impairment of another extremity.

2.00 SPECIAL SENSE ORGANS

A. Causes of disability. Disease or injury of the special sense organs may produce disability by reduction of the ability to see or hear. Loss of central vision results in inability to distinguish detail and prevents reading and fine work. Loss of peripheral vision restricts the ability of an individual to move about freely. Loss of hearing impairs ability to communicate with others by misinterpretation of ideas and orders and results in lack of awareness to danger. The extent of impairment of sight or hearing should be determined by visual or auditory testing.

B. Central visual acuity. A loss of central visual acuity may be caused by impaired distant and/or near vision. However, for an individual to meet the level of severity described in § 2.02 and 2.04 only the remaining central visual acuity for distance of the better eye with best correction using the Snellen test chart may be used. Correction obtained by special visual aids (e.g., contact lenses) will be considered only if the individual has the ability to wear such aids.

C. Field of vision. Disability due to loss of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. For the phakic eye (the eye with a lens), the extent of the remaining visual field will be determined by usual perimetric methods, utilizing a 3 mm. white disc target at a distance of 330 mm. under illumination of not less than 7 foot-candles. For the aphakic eye (the eye without a lens), the visual field must be determined by utilizing a 6 mm. white disc at a distance of 330 mm. without corrective lenses.

Field measurements must be accompanied by notated field charts, a description of the type and size of the target and the test distance. If corrective lenses have been used, this fact must be stated.

D. Muscle function. Paralysis of the third cranial nerve producing ptosis, paralysis of accommodation, and dilation and immobility of the pupil may cause significant visual impairment. When all the muscles of

the eye are paralyzed, including the iris and ciliary body (total ophthalmoplegia), the condition is disabling provided it is bilateral. A finding of disability based primarily on impaired muscle function must be supported by a report of an actual measurement of ocular motility.

E. Visual efficiency. Loss of visual efficiency may be caused by disease or injury resulting in a reduction of central visual acuity and/or visual field. The visual efficiency of one eye is the product of the percentage of central visual efficiency and the percentage of visual field efficiency. (See Tables No. 1 and 2, § 2.09).

F. Special situations. Aphakia represents a visual handicap in addition to the loss of central visual acuity. The term monocular aphakia would apply to an individual who has had the lens removed from one eye, and who still retains the lens in his other eye or to an individual who has only one eye which is aphakic. The term binocular aphakia would apply to an individual who has had both lenses removed. In cases of binocular aphakia, the central visual efficiency of the better eye will be accepted as 75 percent of its value. In cases of monocular aphakia, where the better eye is aphakic, the central visual efficiency will be accepted as 50 percent of its value. (If an individual has binocular aphakia, and the central visual acuity in the poorer eye can be corrected only to 20/200, or less, the central visual efficiency of the better eye will be accepted as 50 percent of its value.)

Ocular symptoms of systemic disease may or may not produce a disabling visual impairment. These manifestations should be evaluated as part of the underlying disease entity by reference to the particular body system involved.

G. Deafness. Deafness should be evaluated in terms of the person's ability to hear and distinguish speech. The degree of functional hearing loss is that loss of hearing and discrimination for speech which is not restorable by a hearing aid. Loss of hearing may be determined with an audiometer or by other appropriate auditory testing. Discrimination for speech may be determined with a speech audiometer or a hearing aid and the use of phonetically balanced word lists (e.g., the PB-50's prepared at Harvard University or the W-22 recordings developed by the Central Institute for the Deaf). These special test lists consist of words selected so that the frequency of speech sounds in the group is the same as the frequency of the same sounds in an average vocabulary of conventional American English.

[blocks in formation]

2.03 Contraction of visual fields. A. To 10 degrees or less from the point of fixation; or B. So the widest diameter subtends an angle no greater than 20 degrees; or

C. To 20 percent or less visual field efficiency.

2.04 Loss of visual efficiency. Visual efficiency of better eye after best correction, 20 percent or less. (The percent of remaining visual efficiency the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.) 2.05

2.06

Complete homonymous hemianopsia.
Total bilateral ophthalmoplegia.

2.07 Meniere's Syndrome. Severe, with frequent and typical attacks, vertigo, deafness, and cerebellar gait.

2.08 Hearing impairments (not correctible by a hearing aid). Manifested by:

A. Absence of air and bone conduction in both ears (auditory perception of not more than one pure tone at high volume will be considered as absence of air and bone conduction); or

B. No more than 40 percent discrimination for speech (ability to hear and understand no more than 40 out of 100 words of special test lists of words using a speech audiometer or hearing aid).

[blocks in formation]

Column !Phakic....

[ocr errors]
[ocr errors]

Use

[ocr errors]

30

1. A lens is present in both eyes.
2. A lens is present in the better eye
and absent in the poorer eye.

3. A lens is present in one eye and the
other eye is enucleated.

2 Monocular.... 1. A lens is absent in the better eye and present in the poorer eye.

2. The lenses are absent in both eyes; however, the central visual acuity

in the poorer eye after best correction is 20/200 or less.

3. A lens is absent from one eye and the other eye is enucleated.

Binocular..... 1. The lenses are absent from both eyes and the central visual acuity in the poorer eye after best correction is greater than 20/200.

TABLE NO. 2-CHART OF VISUAL FIELD SHOWING EXTENT OF NORMAL FIELD AND METHOD OF COMPUTING % OF VISUAL FIELD EFFICIENCY

[graphic][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][subsumed][merged small][merged small]

1. Diagram of right eye illustrates extent of normal visual field as tested on standard perimeter at 3/330 (3 mm. white disc at a distance of 330 mm.) under 7 foot-candles illumination. The sum of the eight principal meridians of this field total 500 degrees.

2. The percent of visual field efficiency is obtained by adding the number of degrees of the eight principal meridians of the contracted field and dividing by 500. Diagram of left eye illustrates visual field contracted to 30 degrees in the temporal and down and out meridians and to 20 degrees in the remaining six meridians. The percent of visual field efficiency of this field is: 6×20+2×30=180÷500=0.36 or 36 percent remaining visual field efficiency, or 64 percent loss.

3.00 RESPIRATORY SYSTEM

A. Cause of disability: The disability produced by respiratory disease usually results from chronic recurrent infection, communicability or from pulmonary insufficiency or a combination of these factors.

B. Pulmonary tuberculosis is a communicable disease and disability is determined primarily on the basis of activity of the disease. Individuals with "inactive" or "quiescent" disease are not considered to be under a disability on the basis of tuberculosis, whereas individuals with "active" tuberculosis are considered to be under a disability.

Those individuals who meet the criteria described in § 3.08 for pulmonary tuberculosis will be found to have a disabling impairment which is expected to last for a period of at least 12 months. Proposed or accomplished surgery will not militate against such a finding. Impairment of pulmonary function due to extensive pulmonary tuberculosis should be evaluated under the appropriate listing.

Documentation. The clinical activity of pulmonary tuberculosis (i.e., active, inactive, or quiescent) and the criteria which describe the extent of the pulmonary lesion on roent

genogram (i.e., minimal, moderate, or far advanced) are defined in the National Tuberculosis Association's publication, "Diagnostic Standards and Classification of Tuberculosis." Tuberculosis will be considered to be present only when Mycobacterium tuberculosis has been demonstrated by a culture, or by guinea pig inoculation, of a specimen(s) from sputum, gastric aspirate, pleural fluid, or lung tissue. A "positive" culture is a culture in which colonies of M. tuberculosis are present. The date of a culture is the date of specimen collection. If the date of collection is unknown, it will be assumed that the specimen was collected 6 weeks prior to the date of the report of the culture. Where specimens have not been cultured or reported monthly, the intervening specimen (s) will be considered to have been negative, if a current specimen is negative. Suspected or questionable cavitary disease identified on the basis of a conventional PA 14 x 17 film will be considered to be non-cavitary.

C. Pathogenic atypical mycobacteria. Pulmonary infection caused by these organisms will be considered under the same criteria as for M. tuberculosis except that specimens ob

tained by gastric aspiration are not acceptable. The pathogenic atypical mycobacteria are contained in Runyon Groups I, III, and IV. The scotochromogens in Group II are not considered pathogens. A report of one to 10 colonies on culture will not be considered as a "positive" culture. The presence of sporadic positive cultures of atypical mycobacteria occurring after disease caused by M. tuberculosis has been established does not denote reactivation of pulmonary tuberculosis.

D. When a respiratory impairment is episodic in nature, as may occur in complications of bronchiectasis and mycotic infections of the lung, the frequency of severe episodes is the criterion for determining level of impairment.

E. Cor pulmonale. Chronic cor pulmonale as used in § 3.11 refers to a condition in which the right ventricle is enlarged as a consequence of a primary respiratory disease. Therefore, the clinical diagnosis of the respiratory disorder must be established by history, physical findings and chest X-ray. Right ventricular enlargement or outflow tract prominence may be difficult to detect on routine PA film, particularly in the presence of chronic obstructive airway disease. Consequently, lateral and oblique films or chest fluoroscopy should be obtained, unless cardiac enlargement is established by the PA film as per § 4.02.

F. Documentation of pulmonary insufficiency. Spirometric studies for evaluation under Tables I, II, and IV must be expressed in liters or liters per minute. The reported maximum voluntary ventilation (MVV) or maximum breathing capacity (MBC) and one second forced expiratory volume (FEV1) should represent the largest of at least three attempts. The MVV or the MBC reported should represent the observed value and should not be calculated from FEV1. The appropriately labeled spirometric tracing, showing distance per second on the abscissa and the distance per liter on the ordinate, must be incorporated in the file. The paper speed to record the FEV, should be sufficiently fast for measurement of volume to the nearest 0.1 liter. The height of the individual must be recorded. Studies should not be performed during or soon after an acute respiratory illness. If wheezing is present on auscultation of the chest, studies must be performed following administration of nebulized bronchodilator. A statement should be made as to the individual's ability to understand the directions, and cooperate in performing the test.

3.01 CATEGORY OF IMPAIRMENTS, RESPIRATORY 3.02 Chronic obstructive airway disease (chronic bronchitis, chronic asthmatic bronchitis or pulmonary emphysema with or without abnormal X-ray findings). With: Spirometric evidence of airway obstruction demonstrated by MVV and FEV, both

[blocks in formation]

3.03 Bronchial

asthma, allergic ΟΥ

atopic (not due primarily to heart disease or bronchial infection). Evaluate under the criteria in § 3.02.

3.04 Diffuse pulmonary fibrosis (sarcoidosis, Hamman-Rich Syndrome, idiopathic interstitial fibrosis, and similar diffuse fibroses substantiated by chest X-ray or tissue diagnosis. This category does not include cases of bronchitis or emphysema with incidental scarring or scattered parenchymal fibrosis on X-ray). With:

A. Total vital capacity equal to, or less than, values specified in Table II below corresponding to the applicant's height.

[blocks in formation]
[blocks in formation]

fibrosis is evident on chest film, under the criteria for pulmonary fibrosis in §3.04.

3.08 Pulmonary tuberculosis (caused by M. tuberculosis or pathogenic atypical mycobacteria). With:

A. Positive culture (or positive guinea pig inoculation) of specimen obtained more than 3 months following onset of disability; or B. Serial X-ray evidence of increasing extent of lesion more than 3 months following onset of disability; or

C. Far-advanced disease with cavitation and positive culture (or positive guinea pig inoculation) of specimen obtained at any time following onset of disability; or

D. Impairment of pulmonary function due to extensive disease should be evaluated under the criteria in § 3.02, §3.04, or § 3.05. 3.09 Mycotic infection of lung. With:

A. Culture of specific organisms from sputa and serial X-ray evidence of increasing or decreasing extent of lesion, both occurring more than 3 months following onset of disability; or

B. Culture of specific organisms from sputa at any time following onset of disability and current X-ray evidence of a lesion and episodes of hemoptysis occurring at least once every 2 months; or

C. Impairment of pulmonary function due to extensive disease should be evaluated under the criteria in § 3.02, § 3.04, or § 3.05. 3.10 Organic loss of speech. With:

A. Laryngectomy or stenosis of the larynx or paralytic aphonia provided there is inability to produce, by the use of some other anatomical part, speech which can be heard, understood, and sustained; or

B. Central nervous system lesion resulting in severe sensory or motor aphasia paralleling the speech impairment under A above.

3.11 Cor pulmonale. With:

A. Congestive heart failure. Evaluate under the criteria in § 4.02; or

B. Right-sided congestive failure as evidenced by peripheral edema and liver enlargement and right ventricular enlargement or outflow tract prominence on X-ray or fluoroscopy.

3.12 Bronchopleural fistula (persistent). With empyema.

4.00 CARDIOVASCULAR SYSTEM

A. Regardless of the cause of heart disease, disability results from one of two principal consequences of the disease. One is congestive heart failure and the other is ischemia or death of heart muscle. In diseases of the arteries and veins, disability may result from impairment of the vasculature in the central nervous system, eyes, kidneys and extremities. The criteria for evaluating both heart and vascular isorders are expressed in terms of symptoms, signs and laboratory findings.

B. Congestive heart failure is considered in the listings under one category regardless of the etiology producing the heart failure (e.g., arteriosclerotic, hypertensive, rheumatic, pulmonary, congenital, or syphilitic heart disease). Congestive heart failure is

« PreviousContinue »