(a)) ceases, as determined without regard to work performed during the period of trial work.

(d) Meaning of "services." When used in this section "services" means any activity, even though not substantial gainful activity, which is performed by an individual in employment during a period of trial work for remuneration or gain, or which is determined to be of a type normally performed for remuneration or gain. Work performed without remuneration merely as a therapeutic measure or purely as a matter of training, or work usually performed in daily routine around the home or in self-care, is not considered "services."

(e) Trial work for certain individuals who have attained age 55 and who are statutorily blind. An individual who has been determined to be under a disability as defined in § 404.1501(a)(1)(ii) shall receive cash benefits during a trial work period only if:

(1) The work in which he engages requires skills or abilities comparable to those required in the work he regularly engaged in prior to blindness or age 55, whichever is later, or

(2) His last previous work ended because of an impairment and the work he engages in requires a significant vocational adjustment.

§ 404.1537 Limitations on eligibility to period of trial work.

(a) Number of periods of trial work. An individual is not eligible for more than one period of trial work in any one period of entitlement to disability insurance benefits or child's insurance benefits based on disability.

(b) Beneficiary who did not serve waiting period. An individual determined to be under a disability who becomes entitled to disability insurance benefits after previously having been entitled to such benefits which terminated, or to a period of disability which ceased, within the 60-month period preceding the first month in which he is under such disability, and who therefore is not required to serve a waiting period (see section 223(c) (2) of the Act), shall not be eligible for a period of trial work with respect to such entitlement period. § 404.1538 Recovery from impairment while working.

An individual's disability may be found to have ceased at any time within a period of trial work (see § 404.1536), if it

is determined on the basis of evidence (other than evidence that the individual performed services during such time) that the individual is no longer statutorily blind or has recovered from his physical or mental impairment to the extent that he is no longer prevented by his impairment or impairments from engaging in substantial gainful activity. § 404.1539 Cessation of disability.

Where it has been determined that an individual is under a disability as defined in § 404.1501, the "disability” shall be found to have ceased:

(a) In the case of an individual entitled to disability insurance benefits or child's insurance benefits based on disability, in the earlier of the following:

(1) The month in which the impairment, as established by the medical or other evidence, is no longer of such severity as to prevent him from engaging in any substantial gainful activity or, in the case of disability under § 404.1501 (a) (1) (ii), no longer constitutes statutory blindness; or

(2) The month in which the individual has regained his ability to engage in substantial gainful activity, or, in the case of disability under § 404.1501(a) (1) (ii), to utilize in substantial gainful activity skills or abilities comparable to those of some gainful activity in which he had previously engaged with some regularity over a substantial period of time, as demonstrated by work activity after application of the provisions in § 404.1536; or

(b) In the case of an individual entitled to widow's or widower's benefits, in the earlier of the following:

(1) The month in which such individual's impairment improves to the point where it no longer constitutes an impairment listed in the appendix to this subpart, or is medically the equivalent thereof; or

(2) The month in which the individual engages in substantial gainful activity.

(c) In any case, where the individual is requested to furnish necessary medical or other evidence or to present himself for a necessary physical or mental examination by a date specified in the request and the individual fails to comply with such request, the month within which the date for compliance falls, unless the Secretary determines that there is good cause for such failure.

1.00

MUSCULOSKELETAL SYSTEM

A. Functional loss may be due to an anatomical loss or to a loss of use of a part due to deformity, adhesions, defective innervation, or other pathology. Pain may be an important factor in causing functional loss, but it must be associated with relevant abnormal findings. Evaluations of musculoskeletal impairments should be supported where applicable by detailed descriptions of ranges of motion, status of the musculature and any sensory, reflex or circulatory deficits and pertinent X-ray findings.

B. Major joints as used herein refer to hip, knee, ankle, shoulder, elbow or wrist and hand. (Wrist and hand considered together as one major joint.)

C. The measurements of restricted motion and ankylosis are based on the technic of measurements described in "Guides to the Evaluation of Permanent Impairment Extremities and Back" by the Committee on Rating of Mental and Physical Impairment, Special Edition, JAMA, February 15, 1958.

1.01 CATEGORY OF IMPAIRMENTS,
MUSCULOSKELETAL

1.02 Rheumatoid arthritis. With: A. History of joint pain and swelling in two or more major joints and morning stiffness persistent on activity; and

B. Signs of joint enlargement, or effusion, and motion limitation with periarticular muscle wasting in two or more major joints; and

C. X-ray evidence of abnormality of a major joint (1.e., osteoporosis or decalcification or narrowing of joint space) and one of the following:

1. Anatomical deformity in one major

joint, such as joint subluxation, contracture, bony or fibrous ankylosis, joint instability, ulnar deviation, or hyperextension, with resultant limitation of motion; or

2. Positive serologic test for rheumatoid factor; or

3. Elevated sedimentation rate (Wintrobe) greater than 20 mm. per hour in females or 10 mm. per hour in males; or

4. Positive C-reactive protein; or

5. Polymorphonuclear leukocytosis in synovial fluid aspirate; or

6. Characteristic histologic changes in biopsy of synovial membrane or subcutaneous nodule.

1.03 Neurogenic arthropathy (e.g., Charcot) affecting at least one major weight-bearing joint or one major joint in each of the upper extremities. With:

A. Instability or subluxation; and

B. Associated loss of sensory modalities in appropriate distribution.

1.04 Hypertrophic (osteo or degenerative), gouty, infectious or traumatic arthritis. With:

A. History of pain and stiffness in the involved joints; and

B. X-ray evidence of joint space narrowing with osteophytosis (exostosis) or bony destruction with erosions and cysts, or subluxation, or ankylosis of involved joints and one of the following:

1. Abduction of both arms at shoulders restricted to less than 90 degrees; or

2. Ankylosis (fibrous or bony consolidation or fixation) of hip at less than 20 degrees or more than 30 degrees of flexion, measured from neutral position; or

3. Ankylosis or fixation of knee at more than 10 degrees from neutral position; or

4. Limitation of flexion of both hips to 50 degrees or less from neutral position (including ankylosis of both hips at any angle);

or

5. Limitation of flexion of both knees to 30 degrees or less from the neutral position (including ankylosis of both knees at any angle); or

6. Combined involvement of single hip and knee in contralateral extremity, with impairment in each as in 4 or 5 above; or

7. Reconstructive surgery or surgical arthrodesis of a major weight-bearing joint (hip, knee, ankle, or tarsal region) and return to full weight-bearing status did not occur, or is not expected to occur within 12 months of onset of disability; or

8. X-ray evidence of lumbar spine abnormalities as in B above with motion of dorsolumbar spine limited to 5 degrees or less from neutral position and impairment of single hip or knee as in 4 or 5 above. 1.05 Disorders of spine. With:

A. Fracture of vertebra, residuals of. With cord involvement with appropriate sensory and motor loss; or

B. Generalized osteoporosis with pain, limitation of back motion, paravertebral

muscle spasm, and compression fracture of a vertebra; or

C. Ankylosis or fixation of cervical or dorsolumbar spine at 30 degrees or more of flexion measured from the neutral position and one of the following:

1. Calcification of the anterior and lateral ligaments as shown by X-ray; or

2. Bilateral ankylosis of sacroiliac joints and abnormal apophyseal articulations as shown by X-ray.

1.06 Tuberculosis of the spine or any major joint. Active.

1.07 Nerve root compression syndrome (due to any cause). With:

A. Pain and motion limitation in back or neck; and

B. Cervical or lumbar nerve root compression as evidenced by appropriate radicular distribution of sensory, motor, and reflex abnormalities.

by

1.08 Osteomyelitis (demonstrated X-ray). A. Peivis, vertebra, femur, tibia or a major joint of an upper or lower extremity, with persistent activity or occurrence of at least 2 episodes in the 6 months since onset of disability manifested by local or systemic signs or laboratory findings (e.g., heat, redness, swelling, drainage, leucocytosis, or increased sedimentation rate); or

B. With multiple localizations and systemic manifestations such as anemia (hematocrit of 30 percent or less) or amyloid changes.

1.09 Amputation of; or anatomical deformity of (i.e., loss of major function due to degenerative changes associated with vascular or neurological deficits, traumatic loss of muscle mass or tendons and X-ray evidence of bony or fibrous ankylosis at an unfavorable angle, joint subluxation instability). A. Both hands; or

B. Both feet; or

C. One hand and one foot.

OT

1.10 Amputation of lower extremity (at or above the tarsal region). A. Hemipelvectomy or hip disarticulation; or

B. Evaluate an amputation associated with peripheral vascular disease or diabetes mellitus under the criteria in § 4.13 or § 9.08; or C. Inability to use prosthesis effectively, without other assistive devices, due to:

1. Vascular disease; or

2. Neurological complications (e.g., loss of position sense); or

3. Stump complications persisting, or expected to persist, for at least 12 months from onset of disability; or

4. Disorder of contralateral lower extremity causing mobility restriction.

1.11 Fracture of femur, tibia, tarsal bone or pelvis. With solid union not evident on X-ray and return to full weight-bearing status did not occur, or is not expected to occur, within 12 months of onset.

1.12 Fractures and/or soft tissue injuries of an upper extremity. A. With non-union of a fracture of the shaft of the humerus,

radius, or ulna under continuing surgical management directed toward restoration of functional use of the extremity and such function was not restored or expected to be restored within 12 months after onset; or B. Requiring a series of staged surgical procedures within 12 months after onset for salvage and/or restoration of major function of the extremity, and such major function was not restored or expected to be restored within 12 months after onset; or

C. After maximum benefit from surgical therapy has been achieved (i.e., there have been no significant changes in physical findings and/or X-ray findings for any 6-month period after the last definitive surgical procedure), the residual of fractures and/or soft tissue injuries of an upper extremity should be evaluated under the criteria in § 1.09 when associated with residual impairment of another extremity.

2.00 SPECIAL SENSE ORGANS

A. Causes of disability. Disease or injury of the special sense organs may produce disability by reduction of the ability to see or hear. Loss of central vision results in inability to distinguish detail and prevents reading and fine work. Loss of peripheral vision restricts the ability of an individual to move about freely. Loss of hearing impairs ability to communicate with others by misinterpretation of ideas and orders and results in lack of awareness to danger. The extent of impairment of sight or hearing should be determined by visual or auditory testing.

B. Central visual acuity. A loss of central visual acuity may be caused by impaired distant and/or near vision. However, for an individual to meet the level of severity described in § 2.02 and 2.04 only the remaining central visual acuity for distance of the better eye with best correction using the Snellen test chart may be used. Correction obtained by special visual aids (e.g., contact lenses) will be considered only if the individual has the ability to wear such aids.

C. Field of vision. Disability due to loss of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. For the phakic eye (the eye with a lens), the extent of the remaining visual field will be determined by usual perimetric methods, utilizing a 3 mm. white disc target at a distance of 330 mm. under illumination of not less than 7 foot-candles. For the aphakic eye (the eye without a lens), the visual field must be determined by utilizing a 6 mm. white disc at a distance of 330 mm, without corrective lenses.

Field measurements must be accompanied by notated field charts, a description of the type and size of the target and the test distance. If corrective lenses have been used, this fact must be stated.

D. Muscle function. Paralysis of the third cranial nerve producing ptosis, paralysis of

accommodation, and dilation and immobility of the pupil may cause significant visual impairment. When all the muscles of the eye are paralyzed, including the iris and ciliary body (total ophthalmoplegia), the condition is disabling provided it is bilateral. A finding of disability based primarily on impaired muscle function must be supported by a report of an actual measurement of ocular motility.

E. Visual efficiency. Loss of visual efficiency may be caused by disease or injury resulting in a reduction of central visual acuity and/or visual field. The visual efficiency of one eye is the product of the percentage of central visual efficiency and the percentage of visual field efficiency. (See Tables No. 1 and 2, § 2.09).

F. Special situations. Aphakia represents a visual handicap in addition to the loss of central visual acuity. The term monocular aphakia would apply to an individual who has had the lens removed from one eye, and who still retains the lens in his other eye or to an individual who has only one eye which is aphakic. The term binocular aphakia would apply to an individual who has had both lenses removed. In cases of binocular aphakia, the central visual efficiency of the better eye will be accepted as 75 percent of its value. In cases of monocular aphakia, where the better eye is aphakic, the central visual efficiency will be accepted as 50 percent of its value. (If an individual has binocular aphakia, and the central visual acuity in the poorer eye can be corrected only to 20/200, or less, the central visual efficiency of the better eye will be accepted as 50 percent of its value.)

Ocular symptoms of systemic disease may or may not produce a disabling visual impairment. These manifestations should be evaluated as part of the underlying disease entity by reference to the particular body system involved.

G. Deafness. Deafness should be evaluated in terms of the person's ability to hear and distinguish speech. The degree of functional hearing loss is that loss of hearing and discrimination for speech which is not restorable by a hearing aid. Loss of hearing may be determined with an audiometer or by other appropriate auditory testing. Discrimination for speech may be determined with a speech audiometer or a hearing aid and the use of phonetically balanced word lists (e.g., the PB-50's prepared at Harvard University or the W-22 recordings developed by the Central Institute for the Deaf). These special test lists consist of words selected so that the frequency of speech sounds in the group is the same as the frequency of the same sounds in an average vocabulary of conventional American English.

2.03 Contraction of visual fields. A. To 10 degrees or less from the point of fixation; or B. So the widest diameter subtends an angle no greater than 20 degrees; or

C. To 20 percent or less visual field efficiency. 2.04

Loss of visual efficiency. Visual efficiency of better eye after best correction, 20 percent or less. (The percent of remaining visual efficiency=the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.) 2.05 Complete homonymous hemianopsia. 2.06 Total bilateral ophthalmoplegia. 2.07 Meniere's Syndrome. Severe, with frequent and typical attacks, vertigo, deafness, and cerebellar galt.

2.08 Hearing impairments (not correctible by a hearing aid). Manifested by:

A. Absence of air and bone conduction in both ears (auditory perception of not more than one pure tone at high volume will be considered as absence of air and bone conduction); or

B. No more than 40 percent discrimination for speech (ability to hear and understand no more than 40 out of 100 words of special test lists of words using a speech audiometer or hearing aid).

Column 1PhakiC.----...

Use

1. A lens is present in both eyes.
2. A lens is present in the better eye
and absent in the poorer eye.
3. A lens is present in one eye and the
other eye is enucleated.

Monocular.... 1. A lens is absent in the better eye
and present in the poorer eye.
2. The lenses are absent in both eyes
however, the central visual acuity
in the poorer eye after best correc-
tion is 20/200 or less.

3. A lens is absent from one eye and the other eye is enucleated.

Binocular..... 1. The lenses are absent from both eyes and the central visual acuity in the poorer eve after best correction is greater than 20/200.

3.00 RESPIRATORY SYSTEM

A. Cause of disability: The disability produced by respiratory disease usually results from chronic recurrent infection, communicability or from pulmonary insufficiency or a combination of these factors.

B. Pulmonary tuberculosis is a communicable disease and disability is determined primarily on the basis of activity of the disease. Individuals with "inactive" or "quiescent" disease are not considered to be under a disability on the basis of tuberculosis, whereas individuals with "active" tuberculosis are considered to be under a disability.

Those individuals who meet the criteria described in § 3.08 for pulmonary tuberculosis will be found to have a disabling impairment which is expected to last for a period of at least 12 months. Proposed or accomplished surgery will not militate against such a finding. Impairment of pulmonary function due to extensive pulmonary tuberculosis should be evaluated under the appropriate listing.

Documentation. The clinical activity of pulmonary tuberculosis (1.e., active, inactive, or quiescent) and the criteria which describe the extent of the pulmonary lesion on roent

genogram (1.e., minimal, moderate, or far advanced) are defined in the National Tuberculosis Association's publication, "Diagnostic Standards and Classification of Tuberculosis." Tuberculosis will be considered to be present only when Mycobacterium tuberculosis has been demonstrated by a culture, or by guinea pig inoculation, of a specimen(s) from sputum, gastric aspirate, pleural fluid, or lung tissue. A "positive" culture is a culture in which colonies of M. tuberculosis are present. The date of a culture is the date of specimen collection. If the date of collection is unknown, it will be assumed that the specimen was collected 6 weeks prior to the date of the report of the culture. Where specimens have not been cultured or reported monthly, the intervening specimen (s) will be considered to have been negative, if a current specimen is negative. Suspected or questionable cavitary disease identified on the basis of a conventional PA 14 x 17 film will be considered to be non-cavitary.

C. Pathogenic atypical mycobacteria. Pulmonary infection caused by these organisms will be considered under the same criteria as for M. tuberculosis except that specimens ob