[Federal Register Volume 68, Number 127 (Wednesday, July 2, 2003)]
[Notices]
[Pages 39611-39614]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-16719]


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SOCIAL SECURITY ADMINISTRATION


Social Security Ruling, SSR 03-1p.; Titles II and XVI: 
Development and Evaluation of Disability Claims Involving Postpolio 
Sequelae

AGENCY: Social Security Administration.

ACTION: Notice of Social Security ruling.

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SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of 
Social Security gives notice of Social Security Ruling, SSR 03-1p. This 
Ruling clarifies the policies of the Social Security Administration for 
developing and evaluating title II and title XVI claims for disability 
on the basis of postpolio sequelae. Postpolio sequelae refer to the 
documented residuals of acute polio infection, as well as other 
disorders that have an etiological link to either the acute polio 
infection or to the chronic deficits that resulted from the infection. 
These disorders typically manifest late in the lives of polio 
survivors, and include such things as postpolio syndrome (also known as 
the late effects of poliomyelitis), the early presence of advanced 
degenerative arthritis, sleep disorders, respiratory insufficiency, and 
various mental disorders.

EFFECTIVE DATE: July 2, 2003.

FOR FURTHER INFORMATION CONTACT: Carolyn Kiefer, Office of Medical 
Policy, Social Security Administration, 6401 Security Boulevard, 
Baltimore, MD 21235-6401, (410) 965-9104 or TTY (410) 966-5609. For 
information on eligibility or filing for benefits, call our national 
toll-free number, 1-800-772-1213 or TTY 1-800-325-0778, or visit our 
Internet Web site, Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION: Although we are not required to do so 
pursuant to 5 U.S.C. 552(a)(1) and (a)(2), we are publishing this 
Social Security Ruling in accordance with 20 CFR 402.35(b)(1).
    Social Security Rulings make available to the public precedential 
decisions relating to the Federal old-age, survivors, disability, 
supplemental security income, and black lung benefits programs. Social 
Security Rulings may be based on case decisions made at all 
administrative levels of adjudication, Federal court decisions, 
Commissioner's decisions, opinions of the Office of the General 
Counsel, and policy interpretations of the law and regulations.
    Although Social Security Rulings do not have the same force and 
effect as the statute or regulations, they are binding on all 
components of the Social Security Administration, in accordance with 20 
CFR 402.35(b)(1), and are relied upon as precedents in adjudicating 
cases.
    If this Social Security Ruling is later superseded, modified, or 
rescinded, we will publish a notice in the Federal Register to that 
effect.

(Catalog of Federal Domestic Assistance, Program Nos. 96.001 Social 
Security--Disability Insurance; 96.006 Supplemental Security Income)

    Dated: June 26, 2003.
Jo Anne B. Barnhart,
Commissioner of Social Security.

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. 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.
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    \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. 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.
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    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

[[Page 39612]]

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.
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    \2\ Except for statutory blindness.
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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.
    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. 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. 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?

    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

[[Page 39613]]

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.
    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).
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    \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.
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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.
    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?

    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.
    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.
    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

[[Page 39614]]

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?

    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?

    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: 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.''

[FR Doc. 03-16719 Filed 7-1-03; 8:45 am]
BILLING CODE 4191-02-P