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Assessing Neurological Disability Corina Azores-Macalintal, M.D., F.P.N.A.

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Presentation on theme: "Assessing Neurological Disability Corina Azores-Macalintal, M.D., F.P.N.A."— Presentation transcript:

1 Assessing Neurological Disability Corina Azores-Macalintal, M.D., F.P.N.A

2 Questions When is the patient neurologically disabled? When is the patient neurologically disabled? What kind of neurological disabilities does neurological diseases brings? What kind of neurological disabilities does neurological diseases brings?

3 Disability Definition: Definition: Inability to engage in any substantial gainful activity by reason of any medically determined physical or mental impairment(s) which can be expected to result to death or which has lasted or can be expected to last for a continuous period of time. Inability to engage in any substantial gainful activity by reason of any medically determined physical or mental impairment(s) which can be expected to result to death or which has lasted or can be expected to last for a continuous period of time.

4 When is the patient neurologically disabled? Mental/ cognitive Mental/ cognitive Visual / auditory Visual / auditory Motor Motor Sensory Sensory Balance and Coordination Balance and Coordination Gait Gait

5 Mental Disability Language dysfunction (Aphasia) Language dysfunction (Aphasia) Executive dysfunction Executive dysfunction Memory dysfunction Memory dysfunction

6 Aphasia Acquired impairment of comprehension and production of verbal language caused by brain damage. Acquired impairment of comprehension and production of verbal language caused by brain damage. Alexia and agraphia often co-exist with aphasia Alexia and agraphia often co-exist with aphasia

7 Aphasia Four areas of language functioning Four areas of language functioning Auditory comprehension Auditory comprehension Repetition Repetition Fluency of verbal expression Fluency of verbal expression Confrontation naming Confrontation naming

8 Aphasia Non-fluent Non-fluent Broca’s Broca’s Transcortical motor Transcortical motor Global Global Mixed Transcortical Mixed Transcortical Fluent Fluent Wernicke’s Wernicke’s Transcortical sensory Transcortical sensory Conduction Conduction Anomic Anomic Auditory comprehension Auditory comprehension Asyntactic Asyntactic Can be asyntactic Can be asyntactic Severe impairment and Severe impairment and Retain prosody Retain prosody Like global Like global Milder than global Milder than global Asyntactic Asyntactic intact intact

9 Aphasia Non-fluent Non-fluent Broca’s Broca’s Transcortical motor Transcortical motor Global Global Mixed Transcortical Mixed Transcortical Fluent Fluent Wernicke’s Wernicke’s Transcortical sensory Transcortical sensory Conduction Conduction Anomic Anomic Verbal expression Verbal expression Agrammatism, aprosodia, apraxia of speech, poor repetition Poor initiation, elaboration, intact repetition,echolalia Limited to automatisms, stereotypies, poor repetition Limited spontaneous, intact repetition, echolalia Nonmeaningful logorrhea, anosognosia Intact repetition, echolalia Conduit d’approche, poor repetition Pauses for word retrieval, intact repetition

10 Aphasia Non-fluent Non-fluent Broca’s Broca’s Transcortical motor Transcortical motor Global Global Mixed Transcortical Mixed Transcortical Fluent Fluent Wernicke’s Wernicke’s Transcortical sensory Transcortical sensory Conduction Conduction Anomic Anomic Typical word retrieval errors Typical word retrieval errors Semantic, verbs worse than nouns No response, perseverations Stereotypies, semantic Neogolisms, semantic, phonemics Semantic, phonemic, circumlocutions Phonemics, semantic Circumlocutions, no response, semantic, nouns worse than verbs

11 Aphasia Non-fluent Non-fluent Broca’s Broca’s Transcortical motor Transcortical motor Global Global Mixed Transcortical Mixed Transcortical Fluent Fluent Wernicke’s Wernicke’s Transcortical sensory Transcortical sensory Conduction Conduction Anomic Anomic Left Hemisphere lesion locations Left Hemisphere lesion locations Inf. Frontal, operculum Dosolateral frontal, or thalamus Large pre-rolandic + post rolandic Watershed/ extrasylvian cortex Superior temporal Temoral-parietal or degenerative Parietal, insula Inferior temporal or thalamus or degenerative

12 Executive Dysfunction Impairments in initiation, intention, planning, sequencing, inhibition, flexibility, monitoring and various complex aspects of attention Impairments in initiation, intention, planning, sequencing, inhibition, flexibility, monitoring and various complex aspects of attention

13 Memory Dysfunction MCI MCI Dementia Dementia

14 Dementia Memory impairment (learning and recall) Memory impairment (learning and recall) One or more: One or more: Aphasia Aphasia Apraxia Apraxia Agnosia Agnosia Dysexecutive function (planning, organizing, sequencing, abstracting) Dysexecutive function (planning, organizing, sequencing, abstracting) *** deficits of sufficient severity to affect social or occupational functioning

15 Limb Apraxia Impaired ability to perform skilled, purposeful limb movements as a result of neurologic dysfunction Impaired ability to perform skilled, purposeful limb movements as a result of neurologic dysfunction ***excluding weakness, akinesia, abnormalities of tone or posture and movement disorders ***excluding weakness, akinesia, abnormalities of tone or posture and movement disorders

16 Limb Apraxia Type Type Limb-kinetic Limb-kinetic Ideomotor Ideomotor Ideational Ideational conceptual conceptual Clinical features Clinical features Impaired ability to make finem precise, independent finger movements Gesture production errors Impaired sequencing of tool use Content errors in tool use, errors in tool selection

17 Limb Apraxia Type Type Limb-kinetic Limb-kinetic Ideomotor Ideomotor Ideational Ideational conceptual conceptual Assessment tasks Assessment tasks Rotate coin between thumb and fingers Gesture to command, gesture imitation Serial acts (e.g. fold letter place in envelope, seal, stamp) Tool-object matching (hammer and nail)

18 Assessment Tools

19 Mini Mental State Examination (MMSE) Orientation Orientation Registration Registration Attention and Calculation Attention and Calculation Recall Recall Language Language

20 Neuropsychological Testing Comprehensive examinations may be used to establish the existence and extent of compromise of brain function Comprehensive examinations may be used to establish the existence and extent of compromise of brain function

21 Neuropsychological Testing Cerebral dominance Cerebral dominance basic sensation and perception basic sensation and perception motor speed and coordination, motor speed and coordination, attention and concentration, attention and concentration, visual-motor function visual-motor function memory across verbal and visual modalities memory across verbal and visual modalities Receptive and expressive speech Receptive and expressive speech Higher-order linguistic operations Higher-order linguistic operations Problem-solving Problem-solving Abstraction ability Abstraction ability General intelligence General intelligence

22 Neuropsychological Testing Should include evaluating pathological features as: Should include evaluating pathological features as: Emotional lability Emotional lability Abnormality of mood Abnormality of mood Impaired impulse control Impaired impulse control Passivity and apathy Passivity and apathy Inappropriate social behavior Inappropriate social behavior

23 Criteria for Organic Mental Disorder

24 A. Loss of specific cognitive abilities and medically documented persistence of at least one of the FF: Disorientation to time and place, or Disorientation to time and place, or Memory impairment (short-term, intermediate, or long- term), or Memory impairment (short-term, intermediate, or long- term), or Perceptual or thinking disturbances (e.g. hallucinations, delusions, or Perceptual or thinking disturbances (e.g. hallucinations, delusions, or Change in personality, or Change in personality, or Disturbance in mood, or Disturbance in mood, or Emotional lability (e.g. explosive temper outbursts, sudden crying…) and impairment of impulse control Emotional lability (e.g. explosive temper outbursts, sudden crying…) and impairment of impulse control Loss of measured intellectual ability of at least 15 I.Q points from premorbid levels or severely impaired range on neuropsychological testing Loss of measured intellectual ability of at least 15 I.Q points from premorbid levels or severely impaired range on neuropsychological testing

25 And B. Resulting in at least two of the following Marked restriction of activities of daily living; or Marked restriction of activities of daily living; or Marked difficulties in maintaining social functioning; or Marked difficulties in maintaining social functioning; or Marked difficulties in maintaining concentration, persistence, or pace; or Marked difficulties in maintaining concentration, persistence, or pace; or Repeated episodes of decompensation, each of extended duration Repeated episodes of decompensation, each of extended duration

26 OrC. Medically documented history of chronic organic mental disorder of at least 2 years and one of the following: Repeated episodes of decompensation, each of extended duration Repeated episodes of decompensation, each of extended duration A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate

27 Current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement Current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement

28 Visual Presentations: Presentations: Visual loss/blurring Visual loss/blurring Visual field defects (anopsia) Visual field defects (anopsia) Assessment Assessment Field testing Fundoscopy Visual acuity test (Snellen) VEP

29 auditory Presentation: Presentation: Deafness Deafness Tinnitus Tinnitus Dizziness Dizziness Assessment Assessment Weber, Rinne’s Audiogram BAER

30 Motor, sensory, balance, coordination and gait disabilities Motor, sensory, balance, coordination and gait disabilities = disorganization of motor function

31 Disorganization of Motor function In the form of paresis or paralysis, tremor or other involuntary movements, ataxia, sensory disturbances which may occur singly or in various combinations In the form of paresis or paralysis, tremor or other involuntary movements, ataxia, sensory disturbances which may occur singly or in various combinations

32 Disorganization of Motor function Assessment of impairment depends on the degree of interference with locomotion and/or interference with the use of fingers, hands and arms. Assessment of impairment depends on the degree of interference with locomotion and/or interference with the use of fingers, hands and arms.

33 Assessment Motor Strength Motor Strength Sensory Sensory Light touch, pressure, heat / cold, proprioception Light touch, pressure, heat / cold, proprioception *** abnormal sensation as dysaesthesia, allodynia, hyperaesthesia

34 Assessment Balance, coordination and gait Balance, coordination and gait Finger to nose test / heal to shin test Finger to nose test / heal to shin test Tandem walking Tandem walking

35 Category of Neurological Impairments

36 Convulsive Seizure Degree of impairment Degree of impairment Determined according to type, frequency, duration and sequelae Determined according to type, frequency, duration and sequelae At least 1 detailed description of a typical seizure At least 1 detailed description of a typical seizure Presence of associated signs/ symptoms Presence of associated signs/ symptoms Documentation with at least 1 EEG Documentation with at least 1 EEG

37 Convulsive seizure Only if impairment persists despite treatment Only if impairment persists despite treatment Blood levels of anticonvulsant medications Blood levels of anticonvulsant medications Compliance to anticonvulsant medication Compliance to anticonvulsant medication Idiosyncrasy in absorption or metabolism Idiosyncrasy in absorption or metabolism Use of alcohol or drug interactions Use of alcohol or drug interactions

38 Convulsive Seizure Category of impairments: Category of impairments: Major motor seizures: (grand mal or psychomotor) Major motor seizures: (grand mal or psychomotor) Occuring > 1 / month, in spite of at least 3 months of prescribed treatment with: Occuring > 1 / month, in spite of at least 3 months of prescribed treatment with: Daytime episodes Daytime episodes Nocturnal episodes with residuals ( significantly interfering with activity during the day) Nocturnal episodes with residuals ( significantly interfering with activity during the day)

39 Convulsive Seizure Minor motor seizures: (petit mal, psychomotor or focal) Minor motor seizures: (petit mal, psychomotor or focal) > 1x / week in spite of at least 3 months of prescribed treatment > 1x / week in spite of at least 3 months of prescribed treatment With alteration of consciousness and transient postictal manifestations of conventional behavior or significant interference with activity during the day With alteration of consciousness and transient postictal manifestations of conventional behavior or significant interference with activity during the day

40 Vascular Accidents (> 3 most post=vascular accident) Sensory or motor aphasia resulting in ineffective speech or communication; or Sensory or motor aphasia resulting in ineffective speech or communication; or Significant or persistent disorganization of motor function in two extremities, resulting in sustained disturbances of gross and dexterous movements, or gait and station. Significant or persistent disorganization of motor function in two extremities, resulting in sustained disturbances of gross and dexterous movements, or gait and station. Depends on the degree of interference with locomotion and/or interference with the use of fingers, hands and arms Depends on the degree of interference with locomotion and/or interference with the use of fingers, hands and arms

41 Brain Tumors Definitive diagnosis Definitive diagnosis Histologically malignant tumor – pathological diagnosis alone will be the decisive criterion for severity and expected duration Histologically malignant tumor – pathological diagnosis alone will be the decisive criterion for severity and expected duration Other tumors – severity and duration of the impairment will be determined on the basis of symptoms, signs and pertinent laboratory findings Other tumors – severity and duration of the impairment will be determined on the basis of symptoms, signs and pertinent laboratory findings Persistence of the tumor Persistence of the tumor

42 Brain tumors The site of primary, recurrent and metastatic lesion must be specified- in malignant neoplastic diseases The site of primary, recurrent and metastatic lesion must be specified- in malignant neoplastic diseases Operative procedure or hospitalization with findings of surgery and results of pathologist’s gross and microscopic examination of tissues Operative procedure or hospitalization with findings of surgery and results of pathologist’s gross and microscopic examination of tissues

43 Brain Tumors Maligant gliomas( astrocytomas grades III- IV, glioblastoma multiforme) medulloblastoma, epenymoblastoma, primary sarcoma) or Maligant gliomas( astrocytomas grades III- IV, glioblastoma multiforme) medulloblastoma, epenymoblastoma, primary sarcoma) or Astrosarcoma (grades I-II), meningioma, pituitary tumors, oligodendroglioma, epndymoma, clivus chordoma and benign tumors Astrosarcoma (grades I-II), meningioma, pituitary tumors, oligodendroglioma, epndymoma, clivus chordoma and benign tumors

44 Brain Tumors Assessment based on: Assessment based on: Secondary Epilepsy, major or minor Secondary Epilepsy, major or minor > 3 months of > 3 months of Sensory or motor aphasia Sensory or motor aphasia Significant or persistent disorganization of motor function Significant or persistent disorganization of motor function Secondary mental disorders Secondary mental disorders

45 Parkinsonian syndrome Significant rigidity, bradykinesia or tremor in two extremities which singly or in combination, result in sustained disturbance of gross and dexterous movements, or gait and station Significant rigidity, bradykinesia or tremor in two extremities which singly or in combination, result in sustained disturbance of gross and dexterous movements, or gait and station

46 Cerebral Palsy IQ of 70 or less; or IQ of 70 or less; or Abnormal behavior patterns, as destructive or emotional instability Abnormal behavior patterns, as destructive or emotional instability Significant interference in communication due to speech, hearing or visual defect; or Significant interference in communication due to speech, hearing or visual defect; or Disorganization of motor functions Disorganization of motor functions

47 Spinal cord or nerve root lesions Disorganization of motor function Disorganization of motor function

48 Other Episodic conditions Multiple sclerosis/ myasthenia gravis Multiple sclerosis/ myasthenia gravis Frequency and duration of exacerbation Frequency and duration of exacerbation Length of remissions Length of remissions Permanent residuals Permanent residuals

49 Multiple Sclerosis I. Disorganization of motor function Significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station Significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station

50 Multiple Sclerosis II. Visual impairments Impairment of central visual acuity Impairment of central visual acuity Contraction of peripheral visual fields in the better eye Contraction of peripheral visual fields in the better eye Loss of visual efficiency Loss of visual efficiency

51 Multiple Sclerosis III. Mental impairments History and PE or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities History and PE or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities

52 Multiple Sclerosis IV. Significant reproducible fatigue of motor function with substantial muscle weakness on repetitive activity, demonstrated of PE with CNS correlation - use of assessment scale - evoke response tests during exercise

53 Myasthenia Gravis Significant difficulty with speaking, swallowing or breathing while on prescribed therapy; or Significant difficulty with speaking, swallowing or breathing while on prescribed therapy; or Significant motor weakness of muscles of extremities on repetitive activity against resistance while on prescribed therapy Significant motor weakness of muscles of extremities on repetitive activity against resistance while on prescribed therapy

54 Amyotrophic lateral sclerosis Significant bulbar signs Significant bulbar signs Disorganization of motor function Disorganization of motor function

55 Anterior Poliomyelitis Persistent difficulty with swallowing or breathing Persistent difficulty with swallowing or breathing Unintelligible speech Unintelligible speech Disorganization of motor function Disorganization of motor function

56 Muscular Dystrophy Disorganization of motor function Disorganization of motor function

57 Tabes Dorsalis Tabetic crisis occuring more frequently than once monthly; or Tabetic crisis occuring more frequently than once monthly; or Unsteady, broad based or ataxic gait causing significant restriction of mobility substantiated by appropriate posterior column signs Unsteady, broad based or ataxic gait causing significant restriction of mobility substantiated by appropriate posterior column signs

58 Subacute combined cord Degeneration Disorganization of motor function, not significantly improved by prescribed treatment Disorganization of motor function, not significantly improved by prescribed treatment

59 Degenerative disease (Huntington’s chorea, Friedreich’s ataxia, and Spino- cerebellar degeneration, Alzhiemer’s dementia…) Disorganization of motor function Disorganization of motor function Chronic brain syndrome Chronic brain syndrome

60 Traumatic Brain Injury May result in neurological and mental impairments with a wide variety of posttraumatic s/sx May result in neurological and mental impairments with a wide variety of posttraumatic s/sx May need to defer adjudication of the claim at least 6 months post-injury May need to defer adjudication of the claim at least 6 months post-injury

61 Traumatic Brain Injury Evaluated according to: Evaluated according to: Secondary seizure Secondary seizure Secondary motor or sensory aphasia Secondary motor or sensory aphasia Significant or persistent disorganization of motor function Significant or persistent disorganization of motor function Cognitive dysfunction Cognitive dysfunction

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