Superseded by SSR 95-5p
EFFECTIVE DATE: 7/20/88
SSR 88-13: POLICY INTERPRETATION RULING
TITLES II AND XVI:
EVALUATION OF PAIN AND OTHER SYMPTOMS
This ruling supersedes Program Policy Statement (PPS) No. 82 (Social Security Ruling (SSR) 82-58), Titles II and XVI: Evaluation of Symptoms.
PURPOSE: The purpose of this interpretive ruling is to supersede SSR 82-58 and to reiterate our policy on the evaluation of pain and other symptoms as contained in 20 CFR 404.1529 and 416.929, as endorsed by Congress in section 3(a) of Public Law 98-460, and to provide guidance on the consideration to be given to symptoms, including pain, in the evaluation of disability under titles II and XVI of the Social Security Act.
CITATIONS (AUTHORITY): Sections 223(d), 216(i), and 1614(a) of the Social Security Act, as amended; Regulations No. 4, sections 404.1508, 404.1528, and 404.1529; and Regulations No. 16, sections 416.908, 416.928, and 416.929.
INTRODUCTION: Symptoms such as pain, shortness of breath, weakness, or nervousness are the individual's own perceptions of the effects of a physical or mental impairment(s). Because of their subjective characteristics and the absence of reliable techniques for measurement, symptoms (especially pain) are difficult to prove, disprove, or quantify. This policy interpretation explains the need for a sound medical basis for the disability decision and emphasizes the importance of the consideration to be given to symptoms in the evaluation of impairment severity and functional limitation.
POLICY INTERPRETATION: Proper consideration of the effect of pain and other symptoms on an individual's ability to work is an important part of the disability evaluation process. Because pain is subjective and not susceptible to measurement by reliable techniques, the existence if pain and the extent to which pain affects the individual's functional ability to do basic work activities is difficult to evaluate.
Need to Establish a Medically Determinable Impairment
Pain cannot be found to have a significant effect on a disability determination or decision unless medical signs or laboratory findings show that a medically determinable physical or mental impairment is present that could reasonably be expected to produce the pain alleged.
When medical signs and laboratory findings do not substantiate any physical impairment capable of producing the alleged pain (and a favorable determination cannot be made on the basis of the total record), the possibility of a mental impairment as the basis for the pain should be investigated.
Consideration of Pain In Establishing the Severity
of a Medically Determinable Impairment
Once a medically determinable physical or mental impairment is documented, the effects of pain must be considered at each step of the sequential evaluation process.
- 1. IS THE CONDITION SEVERE?
- To be found disabled, an individual must have a medically determinable severe impairment(s). To be considered severe, the impairment or combination of impairments must have more than a minimal effect on the individual's physical or mental abilities to do basic work activities. In determining whether an impairment(s) is severe, full consideration is to be given to all material evidence, including signs, symptoms (such as pain), and laboratory findings. Objective findings may confirm that the individual has a severe impairment. If they do not, the degree of pain must be considered. Where the degree of pain reported is reasonably consistent with the objective medical evidence presented, the conclusion that the impairment is severe must be based on a determination that the total evidence, including the alleged pain, establishes that the individual's ability to do basic work activities is affected to more than a minimal degree. However, where the degree of pain alleged is significantly greater than that which can be reasonably anticipated based on the objective physical findings, the adjudicator must carefully explore any additional limitation(s) imposed by the pain on the individual's functional ability beyond those limitations indicated by the objective medical evidence before any conclusions about severity can be reached.
- 2. ARE THE FINDINGS ABOUT THE INDIVIDUAL'S IMPAIRMENT IDENTICAL TO THOSE IN THE LISTING?
- Disability may be established on a medical basis alone if the criteria of the impairment cited in the Listing of Impairments are met. Some listed impairments include symptoms among the requisite criteria. For example, Listing 1.04 requires a history of joint pain and stiffness. When a symptom, such as pain, appears as a criterion (as in Listing 1.04), it is ordinarily essential only that the symptom be present in combination with the remaining criteria. Unless specifically indicated (as in Listing 1.04A, which requires that abduction of both arms at the shoulders, including scapular motion, be restricted to less than 90 degrees), quantification or evaluation of the intensity or of the functionally limiting effects of that symptom is not required to determine whether the documented findings meet the requisite criteria.
- 3. ARE THE FINDINGS ABOUT THE INDIVIDUAL'S IMPAIRMENT(S) EQUIVALENT TO THOSE FOR AN IMPAIRMENT(S) IN THE LISTING?
- In considering whether documented findings and symptoms are of equivalent severity to the requisite findings and symptoms of a listed impairment, look to see whether the set of symptoms, signs, and findings present are of equal or greater significance than those in the listed criteria. However, an alleged or reported increase in the intensity of a symptom, cannot be substituted no matter how severe, for a missing or deficient sign or finding to elevate impairment severity to equivalency to the listed impairment. For example, a history of severe, persistent joint pain cannot be substituted for the required x-ray evidence of either joint space narrowing or bony destruction (with erosions or cysts) in Listing 1.04 to draw a conclusion of "equal."
Consideration of the Intensity and Persistence
of Pain in Determining Functional Capacity
If the listing is not met or equaled, a residual functional capacity (RFC) assessment is necessary to determine the effects of the impairment, including any additional limitations imposed by pain, on the claimant's capacity to perform former work or other work. Medical history and objective medical evidence such as evidence of muscle atrophy, reduced joint motion, muscle spasm, sensory and motor disruption, are usually reliable indicators from which to draw reasonable conclusion about the intensity and persistence of pain and the effect such pain may have on the individual's work capacity. Whenever available, this type of objective medical evidence must be obtained and must be considered in reaching a conclusion as to whether the individual is under a disability.
There are situations in which an individual's alleged or reported symptoms, such as pain, suggest the possibility of a greater restriction of the individual's ability to function than can be demonstrated by objective medical evidence alone. In such cases, reasonable conclusions as to any limitations on the individual's ability to do basic work activities can be derived from the consideration of other information in conjunction with medical evidence. This is consistent with court decisions which require that statements of the claimant or his/her physician as to the intensity and persistence of pain or other symptoms which may reasonably be accepted as consistent with the medical signs and laboratory findings are to be included in the evidence to be considered in making a disability determination.
When the claimant indicates that pain is a significant factor of his/her alleged inability to work, and the allegation is not supported by objective medical evidence in the file, the adjudicator shall obtain detailed descriptions of daily activities by directing specific inquiries about the pain and its effects to the claimant, his/her physicians from whom medical evidence is being requested, and other third parties who would be likely to have such knowledge.
In developing evidence of pain or other symptoms, it is essential to investigate all avenues presented that relate to subjective complaints, including the claimant's prior work record and information and observations by treating and examining physicians and third parties, regarding such matters as:
- 1. The nature, location, onset, duration frequency, radiation, and intensity of any pain;
- 2. Precipitating and aggravating factors (e.g., movement, activity, environment conditions);
- 3. Type, dosage, effectiveness, and adverse side-effects of any pain medication;
- 4. Treatment, other than medication, for relief of pain;
- 5. Functional restrictions; and
- 6. The claimant's daily activities.
Importance of Consideration Allegations of
Pain in Assessing RFC and Explaining Conclusions Reached
In evaluating a claimant's subjective complaints of pain, the adjudicator must give full consideration to all of the available evidence, medical and other, that reflects on the impairment and any attendant limitations of function.
The RFC assessment must describe the relationship between the medically determinable impairment and the conclusions of RFC which have been derived from the evidence, and must include a discussion of why reported daily activity restrictions are or are not reasonably consistent with the medical evidence.
In instances in which the adjudicator has observed the individual, the adjudicator is not free to accept or reject that individual's subjective complaints solely on the basis of such personal observations. Rather, in all cases in which pain is alleged, the determination or decision rationale is to contain a thorough discussion and analysis of the objective medical evidence and the nonmedical evidence, including the individual's subjective complaints and the adjudicator's personal observations. The rationale is then to provide a resolution of any inconsistencies in the evidence as a whole and set forth a logical explanation of the individual's capacity to work.
EFFECTIVE DATE: The policy explained herein was effective on August 20, 1980, the date the regulations covering the basic policy in the subject area were effective (45 FR 55566).
CROSS-REFERENCE: Program Operations Manual System, section DI 24515.060.