Effective Ambulation and Assistive Devices

Effective Ambulation

Definition: Capable of sustaining a reasonable walking pace over a sufficient distance to be able to carry out activities of daily living, and the ability to travel without companion assistance to and from a place of employment or school.

  • The criteria in listing 11.04B regarding "disorganization of motor function resulting in sustained disturbance of gait and station" are comparable to the new functional criteria in the musculoskeletal system.
    • By describing ambulation in 1.00B2b in terms of "the ability to ambulate effectively on a sustained basis," SSA is providing more substance and clarity to listing level severity.
    • SSA is looking at the same level of severity with "inability to ambulate effectively on a sustained basis" as with "sustained disturbance of gait and station."
  • Accurate determination of function requires detailed functional Activities of Daily Living (ADLs).
    • Often a claimant’s description of ADLs is vague.
    • Complete the ADL portion of SSA forms with good detail to clearly show the DDS that your claimant’s hand or ambulatory function is ineffective.
    • Don’t expect the adjudicator at DDS to call the claimant and verify a detailed level of function, though some better adjudicators will.
    • Let your claimant know there must be consistency in what he or she reports as a level of function throughout their file, including:
      • Functional descriptions on forms.
      • Function they report to their treating doctor.
      • Function they report to a consultative exam (CE) doctor, including mental doctors.
        • It is not uncommon that mental CE reports contain detailed functional ADLs.

Examples of ineffective ambulation:

  • Inability to walk without the use of a walker, two crutches or two canes.
  • Inability to walk a block at a reasonable pace on rough or uneven surfaces.
    • Woods, broken sidewalks, and curbs are considered rough and uneven surfaces for purposes of this example.
    • The inability to walk a block at a reasonable pace on these types of rough and uneven surfaces shows ineffective ambulation.
  • Inability to use standard public transportation.
    • Standard public transportation includes a bus, train (subway) or light rail because these systems work on a fixed route, and the individual has to be able to get to and from the route as well as to get on and off the transportation.
    • Whereas a taxi or car service is not considered “standard public transportation” because they offer a pick up and delivery service, and some drivers assist passengers in entering and leaving the taxi.
  • Inability to carry out routine ambulatory activities, such as shopping or banking.
    • If a person is capable of grocery shopping and going to the mall on their own without difficulty, the DDS will assume they have an effective gait.
  • Inability to climb a few steps at a reasonable pace with the use of a single handrail.
    • If an individual is truly unable to climb even a few steps using a hand rail as an assist, he or she should be found disabled.
    • DDS will look to see if the claimant uses steps to enter their home or if they use stairs in their home.

Note: SSA has instructed DDS that the ability to walk independently about one’s home without the use of an assistive device, in and of itself, does not constitute effective ambulation. DDS has been instructed to assess a person’s true functional ability to walk based on all of the evidence, not just the ability to walk without a cane in their home.

Assistive devices

If an assistive device is medically necessary for ambulation but the medical and non-medical evidence in file does not make that fact clear, DDS may contact the treating source for clarification, or order a CE to address this. Of course, the best source for this answer is the treating source, as a CE doctor does not have an established relationship with the claimant.

It is important to get a treating source to clarify the following:

  • Is the assistive device medically necessary periodically or at all times?
  • Is the assistive device medically necessary on some or all surfaces?
  • What is the medical reason for use of the assistive device?
  • Was the assistive device prescribed; and if so, when and by whom was it prescribed?
    • An assistive device, such as a cane, does not have to be prescribed by a medical doctor to be considered medically necessary.
      • The issue here is not who is prescribing the device, but rather the medical reason it is needed.
      • The medical need or basis, such as weakness, for the use of an assistive device must be confirmed either by
        •  a physician who has treated or examined the individual
        • or by the medical evidence that supports the reason for such device.

Note: As long as evidence from a supporting source, such as a nurse practitioner or physical therapist, is confirmed by the physician or supported by the medical evidence from the physician, it meets the intent of documenting the medical need or basis for the device.

  • One key to the musculokeletal listings is the inability to ambulate effectively.
    • The medical requirement for the use of two canes is given only as an example of ineffective gait in the preamble section 1.00B.2.b.(2).
    • A person who uses one cane could meet a listing, equal a listing, or be a medical-vocational allowance or denial.
    • An individual can meet the listings by virtue of being unable to ambulate effectively even if they do not use an assistive device.
    • There are many factors to consider when a person uses one cane, and SSA emphasizes not focusing on the use of any particular device, but rather the ability to ambulate effectively.

Note: Past relevant work has no bearing on whether an individual's impairment meets or medically equals a listing when that person requires a wheelchair, walker, or 2 canes to ambulate.