A Listing Level Severity

For your condition to be severe enough to meet this listing, you must have had a cerebrovascular accident (CVA). Additionally, ® or ® must be satisfied more than three months after the CVA.

® Sensory or motor aphasia resulting in ineffective speech or communication. This concerns the fact that CVAs in the left hemisphere of the brain may damage language centers and produce aphasia. Receptive aphasias involve knowing, while motor aphasias involve expression through writing or speaking. Motor aphasia is also commonly known as expressive aphasia. Various combinations of receptive and motor aphasia are possible, both regarding severity and specific type of aphasia. A complete (global) aphasia refers to a combination of both receptive and expressive aphasia.

Aphasias can be extremely specific. For example, a receptive aphasia may only involve the inability to understand written words even though they can be seen, inability to identify common objects by touch alone (tactile aphasia), inability to understand spoken words (auditory aphasia) or inability to name objects seen (optic aphasia). Expressive aphasias may involve inability to speak although one knows what to say or inability to write words although one knows what to write. CVAs can also interfere with speech communication by producing dysarthria. ® Significant neurological abnormalities in two extremities (weakness, lack of coordination, etc.) that result in:

• persistent difficulty standing and walking, or

• persistent difficulty using the hands, including both gross and dexterous movements of the fingers.

Part ® involves motor function: the ability to move or coordinate movement. In addition to paralysis, stroke victims often have decreased sensation in the body parts affected—especially numbness—and such sensory abnormalities can also affect motor function. Additionally, lack of coordination in using the arms or hands can result in significant limitations even if there is no loss of strength. For example, loss of strength or coordination in the legs may lead to problems with balancing and walking. The "two extremities" that must be involved for part ® can be both arms, both legs or one arm and one leg combined. If your legs are involved, it is important to be aware that part ® of the listing does not require you to need an assistive device like a cane or crutch to walk. Some more specific considerations regarding your ability to use your arms and legs after a stroke are given in the following several paragraphs.

When a doctor examines you, he or she should carefully test the muscle strength in your lower extremities. The doctor should subjectively test major muscle groups in one leg by having you exert effort with various muscles and then comparing your strength to your other, normal leg. The doctor should also wrap a tape measure around each leg and measure muscle sizes at the thigh and calf. You might have some muscle atrophy from weakness and disuse. Your muscle tone should be noted by the doctor—are any muscles spastic or flaccid? Do you have enough strength in your thigh muscles to arise from a squatting position? Is there enough strength in your calf muscles for you to lift yourself on your toes and walk that way? Are the muscles in the front of your leg strong enough for you to lift your foot and walk on your heels? There are also machines that can reliably measure the force exerted by various muscles. Unfortunately, most doctors don't have this equipment for exact testing of lower extremity muscle strength, nor is it required for the listing. The doctor should also test your ability to maintain balance by observing your tandem gait—how well you can walk placing one foot in front of the other.

Gross movements of the hands are the ability to handle larger objects in lifting, carrying and grasping. For example, grasping a doorknob or other object about the size of a tennis ball or picking up a chair would be a gross movement. Although not required by the listing, grip strength can easily be measured by squeezing a hand ergometer. Unfortunately, most doctors do not use such machines for exact testing. Dexterous movements are those that require more coordination and speed, such as manipulating small objects with good separate control of each individual finger. For instance, playing a musical instrument, sewing, typing, picking up coins and buttoning clothes are all dexterous movements. During physical examinations, you should be able to quickly and easily touch each of your fingertips to your thumb in rapid succession, if your dexterous abilities are intact. The doctor should also observe whether you have any tremors in your hands or arms.

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