Residual Functional Capacity Assessment for Stroke
What Is RFC?
If your stroke is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Limitations on Lifting and Walking
When assessing your RFC, the Social Security Administration should consider the weight that you are able to lift and carry. To be able to do medium work, which requires you to lift and carry up to 50 lbs and stand and walk 6 to 8 hours daily, you should have no more than very modest deficits in strength, coordination, and balance.
If you have some difficulty in walking on your heels and toes, or squatting and arising, during medical examination, you might still be able to do light work (lifting no more than 20 lbs and still standing and walking 6 to 8 hours daily). But you probably would not realistically be able to do even light work if you cannot walk on your heels and toes while carrying no weight during a physical.
In evaluating upper extremity function, the Social Security Administration should consider whether you have insufficient strength to operate arm or leg controls more than occasionally in the affected limbs.
Of course, all factors have to be considered: where your CVA is located, how large it is, whether your muscles appear weak and limp on exam or spastic (in spasm), whether you are overweight etc. Thus, your RFC could be reduced to sedentary work requiring no more than 2 hours standing and walking daily. If you also have significant upper extremity dysfunction, you would be disabled under a listing.
If both your legs are impaired, and your upper extremities are functionally intact, the impairment will meet Listing 11.04B and your will be disabled if your gait and station are impaired to a significant degree—that is, if you cannot stand and walk 6 to 8 hours daily, and you have a problem standing because of balance insufficient for sedentary work. If gait and station are fully functional for sedentary work, except for enough stamina or strength to stand and walk for more prolonged periods, and your upper extremity function is fully intact, then you are capable of a sedentary work RFC.
Limitations on Activities of Daily Living
You—or family members or care givers as appropriate—should be asked in detail about your ability to carry out activities of daily living. Of particular interest is your ability to walk up and down steps, the speed at which you walk, and how easily you tire. If you cannot walk a block, you certainly cannot stand and walk 6 to 8 hours daily. You should also be asked what tasks you could do before your stroke that you cannot do now. Can you dress without assistance? Manipulative functions are important. Can you turn a doorknob? Can you pick up coins and button shirts?
Cerebral Aneurysms and Vascular Malformations
There are no absolute rules for assessing the RFC of persons with cerebral aneurysms and vascular malformations. Assessing these impairments involves considerable medical judgment. Here are some guidelines that Social Security Administration ought to follow.
If you have an un-operated cerebral artery aneurysm or vascular malformation that does not meet or equal a listing, you should not be given higher than a RFC for light work even if you have no neurological abnormalities. This RFC would be given to minimize the risk of a hemorrhagic CVA that might be caused by heavier work that would raise your blood pressure. The risk is even greater if you have uncontrolled high blood pressure (hypertension), multiple or large aneurysms or vascular malformations.
If your aneurysm or vascular malformation has bled in the brain and definitive surgical repair was not possible, the RFC should not be higher than sedentary work or at most, light work, even if you have no neurological deficits. Obviously, if an intracranial bleed occurred spontaneously then it has a high risk of recurrence and exertion should be minimized. There is no scientific data regarding what level of exertion is safe for people with cerebral aneurysms and vascular malformations because no one would be crazy enough to create such a study or enroll in it.
Un-operated cerebral artery aneurysms or vascular malformations that have not bled and do not meet or equal a listing are difficult to evaluate. If the aneurysm is large—10 mm in diameter or more—you should not be given higher than an RFC for light work even if you have no neurological abnormalities. This RFC would be given to minimize the risk of a hemorrhagic CVA that might be caused if the aneurysm ruptures due to increases in blood pressure during exercise. The risk is even greater if you have uncontrolled hypertension (high blood pressure), multiple or large aneurysms or vascular malformations. Since hypertension is a risk factor for strokes, it is not unreasonable to suspect that higher blood pressures increase the risk of bleeding from cerebral aneurysms.
A person with a small aneurysm of 7 mm or less and no neurologic abnormalities and no uncontrolled hypertension might not be functionally restricted, while a 7 mm aneurysm in the presence of significant hypertension might justify a restriction to medium work. There is no way to avoid medical judgment in this area. There is no study showing that small cerebral aneurysms that have never bled produce any functional restriction or are more likely to bleed with normal blood pressure and even heavy exercise. In fact, since many such aneurysms are discovered incidentally, a significant number of people must have engaged in heavy exertion of various types without ill results.
If you have a large cerebral aneurysm—say 7 mm or more—and have had surgical clipping or coiling after an episode of bleeding (subarachnoid hemorrhage), your RFC would probably be medium work or no limitation, if you are otherwise asymptomatic without uncontrolled high blood pressure. If bleeding had occurred previously, or if you have uncontrolled hypertension, light work or medium work would be more appropriate even if surgery has been done—provided there was good surgical control of the aneurysm.
Most neurologists performing examinations on post-CVA claimants do not even comment on the possibility of paralysis of the diaphragm, although it can significantly affect ability to breath. This area is often not given sufficient consideration by Social Security Administration adjudicators. If the medical evidence is not clear, you and your doctors should be asked about any breathing difficulties you have. Pulmonary function studies can make the difference between allowance and denial.
Some neurologists do not check claimants for more subtle abnormalities that could have significant impact on RFC, such as the ability to identify an object placed in the hand without looking at it. You and your family members should bring to your doctor’s attention any information you may have about subtle, but important deficits like this.
Facial paralysis to various degrees occurs fairly frequently. Drooling, loss of facial expression, speech articulation problems, and difficulty eating are some of the functional problems that can result from a CVA that would affect RFC.