Disability Doc

Effective Hand Function

Effective fine and gross movement - capable of sustaining such functions as reaching, pushing, pulling, grasping, and fingering to be able to carry out activities of daily living.

Inability to perform fine and gross movements effectively - extreme loss of function of both upper extremities, i.e., an impairment that interferes very seriously with the individual's ability to independently initiate, sustain or complete activities.

Examples of inability to perform fine and gross movements effectively:

• Inability to prepare a simple meal and feed oneself.
  • Does someone have to feed the claimant?
    • Pretty rare unless the claimant clearly meets a listing.
  • Inability to take care of personal hygiene.
    • Do they present to the mental CE impeccably groomed with makeup and nails done?
      • Many mental CE doctors will make note of this fact, and odds are, the claimant did not have someone do this for them.
    • Inability to sort and handle papers or files.
      • Does the claimant present to the field office interview and have no observed difficulties writing or using their hands?
      • Are the forms submitted by claimants completed with neat handwriting or neatly typed?
        • If claimants are able to complete those forms without assistance, DDS may consider they have effective hand function.
      • Inability to place files in a file cabinet at or above waist level.

The term “repetitive”

• From a vocational standpoint, treating sources often use the term “repetitive” in opining functional restrictions.
  • The term “repetitive” is not a defined SSA term, and as such, has no specific quantitative meaning in the program.
• SSA and the Dictionary of Occupational Titles (DOT) use the following terms to quantify pushing/pulling and manipulative function:
  • Never.
  • Occasional – occurring from very little up to 1/3 of an 8-hour work day.
  • Frequent – occurring from 1/3 to up to 2/3 of an 8-hour work day.
  • Constant – occurring from 2/3 to constantly in an 8-hour work day (equivalent to “unlimited” and “none established” in the RFC).

Manipulative limitations

• SSA and the DOT define “manipulation” as reaching, handling, fingering and feeling.
• The Residual Functional Capacity (RFC) form requires adjudicators to quantify any manipulative limitations.
  • The term "occasional" must be defined specifically enough to determine if the limitation is extreme.
    • In the context of Medical-Vocational Guidelines, “occasional” is defined as "occurring very little up to 1/3 of the time".
    • SSA considers a limitation of "very little" pushing, pulling, reaching, fingering, or handling to be consistent with an extreme limitation, while being able to perform these activities "one-third of the time" would not represent an extreme limitation.
    • Any limitations specified using terms like "occasional" may or may not represent an extreme limitation of functioning.
    • Depending on their intention, it is important to have a treating source specifically define this term if they use it.
      • Preferably by saying “very little,” if the source considers there to be an extreme limitation.

DDS hand specialist instructions

In the July-August 1999 issue of the “NADE Advocate, Kenneth Bussan, M.D., a hand specialist with the Wisconsin DDS instructed:

• If an RFC, regardless of age or education, is limited to “light” work with an “occasional” or worse restriction in fingering and handling bilaterally, the decision would be an allowance (from a medical-vocational standpoint).
• If a claimant cannot do “frequent” handling, “we eliminate all light work activity, as well as sedentary work.”
  • SSA tends to monitor the “NADE Advocate” for accuracy of instructions to disability examiners, and did not respond to this opinion.
    • It is reasonable to assume that this non-response represents an unspoken agreement with vocational policy.
    • This assumption is further supported by the fact that I have seen the Florida Quality Assurance (QA) department cite this opinion in a QA return.

Objective evidence and hand limitations

• If a person acts as if they have extreme difficulty grasping or manipulating objects in medical records from a treating or evaluating source, that behavior must be objectively supported by the medical evidence.
• It is not enough for the treating or evaluating source to simply say that grip and dexterity are “reduced” - a common statement found in function forms submitted by treating and evaluating sources.
  • The treating or evaluating source MUST quantify the reduction by providing specific examples with graded grip strength and examples of loss of fine and gross dexterity.
  • And the diagnostic and physical evidence MUST support this behavior for it to be considered valid.
  • For example, it should be documented whether the claimant is able to dress and undress without assistance and open and close doors.

• If a doctor opines that a loss of hand function is due to “arthritis,” he or she should provide the following to support this diagnosis:

  • Objective physical findings such as joint deformity, hand swelling, or synovitis (inflammation and swelling).
  • Diagnostic findings, such as abnormal hand x-rays.

  Note: There should not be inconsistencies in file, such as a claimant telling a mental doctor they crochet or do needle point as a hobby, if they allege significant loss of hand function.

  Note: Though the DDS is supposed to consider the issue of sustained manipulative abilities over an 8-hour work day, many adjudicators forget this. You should have treating sources clarify the claimant’s ability to perform sustained gross and fine manipulation over an 8-hour work day.

  Grip strength, lateral pinch and hand atrophy

  • The last sentence of 1.00E1 in the Musculoskeletal System preamble states “A specific description of atrophy of hand muscles is acceptable without measurements of atrophy but should include measurements of grip and pinch strength.”
  • SSA recommends the average ranges listed in the most current "AMA Guide" for both grip and pinch strength assessments. See the following charts. 

  Average grip strength by age in pounds (rounded)

  	Males		Females
  Age	Major hand	Minor hand	Major hand	Minor hand
  <20	100	94	53	50
  20-29	107	102	54	50
  30-39	109	98	68	62
  40-49	108	104	52	47
  50-59	101	96	49	40

  Average strength of lateral pinch in pounds (rounded)

  Males		Females
  Major hand	Minor hand	Major hand	Minor hand
  17	16	11	10

  • However, if the "AMA Guide" or instruments for measuring muscle strength, such as a dynamometer are not available, SSA has instructed that the use of a scale of 0 - 5 for grip strength and for pinch strength assessment would be acceptable. See the following chart.

  Motor strength	Description of muscle function
  5	Active movement against gravity with full resistance
  4	Active movement against gravity with some resistance
  3	Active movement against gravity only, without resistance
  2	Active movement with gravity eliminated
  1	Slight contraction and no movement
  0	No contraction

  • Or a gross description of "mild, moderate, or severe weakness" should include a description as to how the testing was performed.