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Assessing Neurological Disability Corina Azores-Macalintal, M.D., F.P.N.A Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Questions When is the patient neurologically disabled? What kind of neurological disabilities does neurological diseases brings? Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Disability 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. Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. When is the patient neurologically disabled? Mental/ cognitive Visual / auditory Motor Sensory Balance and Coordination Gait Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Mental Disability Language dysfunction (Aphasia) Speech Comprehension Reading and writing Executive dysfunction Memory dysfunction Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Aphasia Acquired impairment of comprehension and production of verbal language caused by brain damage. Loss of ability to understand or express speech Alexia - (inability to see words or to read) and agraphia often co-exist with aphasia Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Aphasia Four areas of language functioning Auditory comprehension Repetition Fluency of verbal expression Confrontation naming Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Non-fluent Broca’s Transcortical motor Global Mixed Transcortical Fluent Wernicke’s Transcortical sensory Conduction Anomic Aphasia Auditory comprehension Asyntactic (no arrangement of words to create a wellformed sentence) Can be asyntactic Severe impairment and Retain prosody (stress and intonation) Like global Milder than global Asyntactic intact Verbal expression Aphasia Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Non-fluent Broca’s Transcortical motor Global Mixed Transcortical Agrammatism, aprosodia, apraxia of speech, poor repetition Poor initiation, elaboration, intact repetition,echolalia Limited to automatisms, stereotypies, poor repetition Limited spontaneous, intact repetition, echolalia Fluent Nonmeaningful logorrhea, anosognosia Wernicke’s Transcortical sensory Intact repetition, echolalia Conduction Anomic Conduit d’approche, poor repetition Pauses for word retrieval, intact repetition Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Non-fluent Broca’s Transcortical motor Global Mixed Transcortical Fluent Wernicke’s Transcortical sensory Conduction Anomic Aphasia Typical word retrieval errors Semantic, verbs worse than nouns No response, perseverations Stereotypies, semantic Stereotypies, semantic Neogolisms, semantic, phonemics Semantic, phonemic, circumlocutions Phonemics, semantic Circumlocutions, no response, semantic, nouns worse than verbs Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Non-fluent Broca’s Transcortical motor Global Mixed Transcortical Fluent Wernicke’s Transcortical sensory Conduction Anomic Aphasia 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Executive Dysfunction Impairments in initiation, intention, planning, sequencing, inhibition, flexibility, monitoring and various complex aspects of attention Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. MCI Dementia Memory Dysfunction Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Dementia Memory impairment (learning and recall) One or more: Aphasia Apraxia - inability to perform purposeful functions Agnosia - inability to interpret sensation and recognize things Dysexecutive function (planning, organizing, sequencing, abstracting) *** deficits of sufficient severity to affect social or occupational functioning Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Criteria for Organic Mental Disorder A. Loss of specific cognitive abilities and medically Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. documented persistence of at least one of the FF: Disorientation to time and place, or Memory impairment (short-term, intermediate, or longterm), or Perceptual or thinking disturbances (e.g. hallucinations, delusions, or Change in personality, or Disturbance in mood, or 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. And B. Resulting in at least two of the following Marked restriction of activities of daily living; or Marked difficulties in maintaining social functioning; or Marked difficulties in maintaining concentration, persistence, or pace; or Repeated episodes of de-compensation, each of extended Or QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. C. medically documented history of chronic organic mental disorder of at least 2 years and one of the following: Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. Repeated episodes of de-compensation, 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Limb Apraxia 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Type Limb-kinetic Ideomotor Limb Apraxia Clinical features Impaired ability to make fine precise, independent finger movements Gesture production errors Ideational Impaired sequencing of tool use conceptual Content errors in tool use, errors in tool selection Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Type Limb-kinetic Ideomotor Ideational conceptual Limb Apraxia Assessment tasks Rotate coin between thumb and fingers Gesture to command, gesture imitation Serial acts (e.g.fold letterm place in envelope, seal, stamp) Tool-object matching (hammer and nail) Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Assessment Tools Mini Mental State Examination (MMSE) Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Orientation Registration Attention and Calculation Recall Language Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Neuropsychological Testing Comprehensive examinations may be used to establish the existence and extent of compromise of brain function Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Neuropsychological Testing Cerebral dominance basic sensation and perception motor speed and coordination, attention and concentration, visual-motor function memory across verbal and visual modalities Receptive and expressive speech Higher-order linguistic operations Problem-solving Abstraction ability General intelligence Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Neuropsychological Testing Should include evaluating pathological features as: Emotional lability Abnormality of mood Impaired impulse control Passivity and apathy Inappropriate social behavior Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Presentations: Visual acuity Visual field defects (anopsia) blindness Visual Assessment Field testing Fundoscopy Visual acuity test (snellen) VEP Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. auditory QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Presentation: Deafness Assessment Weber, rinne’s Associated s/sx Tinnitus, ear discharges, BAER Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Motor, sensory, balance, coordination and gait disabilities = disorganization of motor function Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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. Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Assessment Motor Strength Sensory Light touch, pressure, heat/cold, proprioception *** abnormal sensation as dyseasthesia, allodynia, hypereasthesia Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Assessment Balance, coordination and gait Finger to nose test / heal to shin test Tandem walking Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Category of Neurological Impairments Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Convulsive Seizure Degree of impairment Determined according to type, frequency, duration and sequelae At least 1 detailed description of a typical seizure Presence of associated signs/ symptoms Documentation with at least 1 EEG Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Convulsive seizure Only if impairment persists despite treatment Blood levels of anticonvulsant medications Compliance to anticonvulsant medication Idiosyncrasy in absorption or metabolism Use of alcohol or drug interactions Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Convulsive Seizure Category of impairments: Major motor seizures: (grand mal or psychomotor) Occuring > 1 / month, in spite of at least 3 months of prescribed treatment with: Daytime episodes Nocturnal episodes with residuals ( significantly interfering with activity during the day) Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Convulsive Seizure Minor motor seizures: (petit mal, psychomotor or focal) > 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. Vascular Accidents QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. (> 3 most post=vascular accident) 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. Depends on the degree of interference with locomotion and/or interference with the use of fingers, hands and arms Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Brain Tumors Definitive diagnosis 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 Persistence of the tumor Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Brain tumors 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Brain Tumors 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Brain Tumors Assessment based on: Secondary Epilepsy, major or minor > 3 months of Sensory or motor aphasia Significant or persistent disorganization of motor function Secondary mental disorders Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Cerebral Palsy IQ of 70 or less; or Abnormal behavior patterns, as destructive or emotional instability Significant interference in communication due to speech, hearing or visual defect; or Disorganization of motor functions Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Spinal cord or nerve root lesions Disorganization of motor function Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Episodic conditions Multiple sclerosis/ myasthenia gravis Frequency and duration of exacerbation Length of remissions Permanent residuals Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Multiple Sclerosis II. Visual impairments Impairment of central visual acuity Contraction of peripheral visual fields in the better eye Loss of visual efficiency Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Myasthenia Gravis 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Amyotrophic lateral sclerosis Significant bulbar signs Disorganization of motor function Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Anterior Poliomyelitis Persistent difficulty with swallowing or breathing Unintelligible speech Disorganization of motor function Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Muscular Dystrophy Disorganization of motor function Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Tabes Dorsalis Tabetic crisis occurring more frequently than once monthly; or Unsteady, broad based or ataxic gait causing significant restriction of mobility substantiated by appropriate posterior column signs Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Subacute combined cord Degeneration Disorganization of motor function, not significantly improved by prescribed treatment Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Degenerative disease (Huntington’s chorea, Frieddreich’s ataxia, and Spino-cerebellarr degeneration) Disorganization of motor function Chronic brain syndrome Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Traumatic Brain Injury 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 Qui ck Ti me™and a TIF F (Uncompress ed)dec ompres sor are needed to s ee th i s pi c tu re. QuickTime™ and a TIFF (U ncompressed) decompressor are needed to see this picture. Traumatic Brain Injury Evaluated according to: Secondary seizure Secondary motor or sensory aphasia Significant or persistent disorganization of motor function