Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Abdominal Aortic Aneurysm


Related Terms

  • Abdominal Aneurysm
  • Aneurysm of the Abdominal Aorta
  • Dissecting Abdominal Aneurysm
  • Fusiform Abdominal Aneurysm
  • Saccular Abdominal Aneurysm

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Vascular Surgeon

Comorbid Conditions

  • Anatomic factors (e.g., horseshoe kidney)
  • Blood-clotting abnormalities
  • Chronic obstructive pulmonary disease (COPD)
  • Congestive heart failure (CHF)
  • Gastrointestinal disorders
  • Heart disease
  • Obesity
  • Other vascular disease
  • Respiratory disease

Factors Influencing Duration

Factors that may lengthen disability include the location and size of the aneurysm, the age of the individual, the extent of surgical repair necessary, whether underlying cardiovascular diseases such as hypertension or arteriosclerosis are present, and whether postoperative myocardial infarction or renal failure occurs. The length of disability also depends on job requirements and how rapidly the individual recovers from the surgical procedure. If the job requires strenuous physical labor, the disability will last longer than if work requirements are more sedentary.

Individuals with AAA are generally older and generally have atherosclerosis in other places (such as coronary artery disease, carotid artery disease, or peripheral vascular disease in the legs); thus, many times they are not capable of heavy or very heavy work because of comorbidities, even if the abdominal aorta has been successfully repaired.

Medical Codes

ICD-9-CM:
441.02 - Dissection of Aorta, Abdominal
441.03 - Dissection of Aorta, Thoracoabdominal
441.3 - Abdominal Aneurysm, Ruptured
441.4 - Abdominal Aneurysm without Mention of Rupture
441.6 - Thoracoabdominal Aneurysm, Ruptured, Ruptured
441.7 - Thoracoabdominal Aneurysm

Overview

An abdominal aortic aneurysm (AAA) refers to a localized weakness and ballooning (dilatation) of the aorta in the segment between the kidneys and the branches in the legs (iliac arteries). The aneurysm is termed saccular when it consists of an outward pouching on only one side of the arterial wall. The aneurysm is termed fusiform when the dilatation extends around the circumference of the vessel. When there is actual separation within the wall of the aorta, the aneurysm is termed dissecting; occurring rarely, dissecting aneurysms of the abdominal aorta usually represent an extension of a process beginning in the thoracic aorta.

An AAA begins as small pea-sized dilatation on the aorta. A normal aorta diameter is approximately 2 cm. Aneurysms grow at a rate of about 2.21 millimeters per year, but the growth rate can vary (Sweeting). The US Preventive Services Task Force reports the follow-up recommendations of the Society of Vascular Surgery and the Society of Vascular Medicine and Biology for asymptomatic AAAs under 4.5 cm in diameter. These groups recommend no further action for AAAs less than 3.0 cm, yearly ultrasonographic screening for AAAs between 3.0 and 4.0 cm, biyearly ultrasonographic screening for AAAs between 4.0 and 4.5 cm, and referral to a vascular specialist for AAAs greater than 4.5 cm (USPSTF; Kent). The likelihood of rupture increases as the aneurysm increases in size, and treatment is generally indicated for asymptomatic AAAs over 5.5 cm in diameter (Hope). However, new functional imaging techniques can provide vital information about the internal stresses of the artery that can better estimate the risk of rupture (Hope). In addition, other risk factors like smoking, male gender, high blood pressure (hypertension), advanced age, and diabetes can help to determine the risk of rupture as well (Sweeting), although none of these risk factors were helpful in predicting survival difference between patients undergoing surgical repair and those who were monitored for change (Filardo).

Inflammation is common among patients with AAAs. AAAs caused by infection are rare. Staphylococcus aureus, Salmonella, Streptococcus, Escherichia coli, and C. pneumoniae have been isolated from enlarged aortas (Vilalta).

Incidence and Prevalence: The incidence of AAA is estimated at 3% to 9% of the general population (Vilalta). Every year over 10,000 Americans die of AAA rupture, and AAA contributes to the death of over 17,000 (Murphy; Kochanek; Go).

The frequency of AAA rupture varies from 0.71 to 11.03 per 1,000 individuals (Sweeting). The rate of rupture is dependent on the size of AAA, smoking status, gender (almost 4 times higher risk of rupture among women), age, body mass index (inversely related), and blood pressure (Sweeting). The 1-year rupture rate is about 9% for AAAs of 5.5 to 5.9 cm, 10% for AAAs of 6.0 to 6.9 cm, and 33% for AAAs of 7.0 cm or more (USPSTF).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk for AAA increases with age and is higher among men. Smoking may account for upwards of 70% of all cases of AAA (Lederle). Family history, hardening of the arteries (atherosclerotic vascular disease), hypertension, and high cholesterol level have also been associated with an increased risk of AAA. Chronic obstructive pulmonary disease (COPD) has also been associated with AAA, although the association here was weaker. Female gender, diabetes, and black race were negatively associated with AAA. Overall, smoking, older age, and male gender are the strongest risk factors for AAA (Lederle). However, AAAs in women are far more likely to rupture (Sweeting). Individuals with peripheral vascular disease or connective tissue disorders, as well as those who have experienced trauma, are also at increased risk for AAA (Vilalta).

For more information and an in-depth discussion on risk factors that contribute to aortic disease, refer to "Disease and Injury Causation," pages 238-248.

Source: Medical Disability Advisor



Diagnosis

History: AAAs usually cause no symptoms (asymptomatic) and are most commonly found either during a general physical examination or on an x-ray done for some other reason (Karkos). An individual may not be aware of the condition for quite some time, especially if the aneurysm is small; most cases of AAA remain asymptomatic until they rupture (Pande). In fewer than 50% of cases, individuals may report an abnormally prominent throbbing (pulsating) lump or mass in the abdomen that is easily seen and felt. Constant pain in the lower back region as a result of pressure on the lumbar nerves may be present. The individual may also describe the pain as a steady, gnawing discomfort in the lower back or abdomen.

Symptoms that progress to severe pain in the lower abdomen or back, radiating to the buttocks, groin, or legs, may signal an imminent rupture of the aneurysm. Vomiting and feeling faint (syncope) may also precede AAA rupture. Individuals experiencing excruciating, abrupt, persistent back and / or abdominal pain may have an aneurysm that has already ruptured. Additional symptoms indicating that rupture has occurred include weakness (paresis), as well as symptoms of hypovolemic shock: low blood pressure (hypotension), sweating (diaphoresis), and rapid heart rate (tachycardia). If medical care is not sought immediately, unconsciousness, cardiac arrest, and death may result.

Physical exam: In non-obese individuals, a pulsating mass or swelling in the umbilical area may be evident. A blowing murmur (bruit) can be heard when a stethoscope is placed over the mass (auscultation). Abdominal aneurysms do not cause diminished pulses in the arms. However, diminished pulses in the legs (peripheral pulses) may be present due to atherosclerotic narrowing of the iliac, femoral, or more distal arteries.

Tests: Seventy-five percent of all AAAs are found by chance during self-examination, routine physicals, or diagnostic investigations such as x-ray, intravenous urography, barium tests, ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI), each performed for some other reason (Karkos).

Abdominal ultrasound is a noninvasive test with high specificity (100%) and sensitivity (95%). Serial ultrasound examinations permit following the size of an AAA to determine when elective surgery should be performed (USPSTF).

New functional imaging techniques show promise in assessing the risk of rupture, atherosclerotic regions, and predicting aneurysm growth (Hope).

Source: Medical Disability Advisor



Treatment

Treatment is directed at reducing the risk of aneurysm rupture by timely surgical resection of the aneurysm and replacement or reinforcement of the damaged aortic section with a graft. If the aneurysm is small and produces no symptoms, surgery may be delayed; however, even small aneurysms may rupture. A vascular surgeon should be consulted if the aorta is greater than 3 cm in diameter or if any part of the aortic artery is greater than 1.5 times the diameter of an adjacent section. In general, individuals with an AAA smaller than 4 cm should have yearly ultrasounds to track progress; if the AAA grows larger than 4 cm but smaller than 4.5 cm twice-yearly ultrasounds are recommended. Any AAA 4.5 cm or larger should be referred to a vascular surgeon (Kent).

Urgent but not emergency surgical repair is recommended for aneurysms 5 cm or larger or those that are rapidly becoming larger in individuals without other significant medical problems. Elective surgical repair is often considered for aneurysms between 4 and 6 cm.

Because rupture of an AAA constitutes a medical emergency necessitating immediate surgery, the goal of management is to reduce the risk of rupture. Medications called beta-blockers may be taken to lower blood pressure, thereby decreasing the rate of growth of an AAA. Individuals who smoke are counseled to quit. Regular physical examinations and ultrasound studies are used to detect enlargement that may justify surgical intervention.

Surgical repair of an AAA consists of removal (resection) of the part of the artery affected by the aneurysm (aneurysm resection) and restoration of blood flow using a synthetic or composite graft replacement. This procedure is used in emergency as well as elective situations.

Insertion of an endovascular stent graft may be an option in some cases. A stent is an artificial tube-like device that reinforces the existing arterial wall. The advantage of a stent is that the blood vessel does not need to be excised and blood leakage is less likely, whereas grafts can tear away from the insertion site or leak blood into the abdomen. Stents implanted via an endovascular aneurysm repair (EVAR) access the aorta via a peripheral artery and use catheters to place the stent internally within the aorta while viewing live x-ray pictures of the site. This allows treatment without open resection or removal of the aneurysm, eliminating the need for general anesthesia.

Emergency surgery involves the same procedure as in nonemergency situations, to resect the aneurysm and repair the damaged section of the aorta, with the additional need for stabilizing measures. These measures include the administration of medications to lower blood pressure (antihypertensives), medications to decrease the force of blood vessel contractions (beta-blockers), oxygen for difficulty in breathing, narcotics for pain relief, administration of fluids directly into a vein (intravenous), and, if necessary, whole blood transfusions.

Source: Medical Disability Advisor



Prognosis

Among individuals with a leaking or ruptured AAA, the perioperative death rate is about 50% among those who survive transport to the hospital. Overall the mortality rate upon rupture varies between 78 and 94% (Vilalta). Perioperative mortality is 4%-5% (USPSTF).

Source: Medical Disability Advisor



Complications

If an AAA is not effectively managed, the outcome is rupture. Rupture may result in hypovolemic shock, heart attack, stroke, and death. Complications resulting from surgery include bowel ischemia; kidney failure; pneumonia; movement of emboli to the lower extremities, bowel, or kidneys; and leakage from the graft. Complications from stent placement include perforation of the AAA, and movement of emboli to the lower extremities, bowel, or kidneys.

Untreated AAA may result in the formation of blood clots inside the aneurysm, leading to peripheral embolisms that may migrate to the lower extremities or other organs (Karkos).

Following open AAA repair, about 6% of patients die within 30 days of surgery, nearly 3% will experience a heart attack (myocardial infarction), 0.6% renal failure, almost 2% stroke, 14% will have to have additional surgery and in 0.1% the aneurysm will rupture (Stather). Following endovascular repair, about 2% of patients will die within 30 days of surgery, about 2.2% will experience a myocardial infarction, 1.0% renal failure, about 2.5% stroke, over 26% will have to have additional surgery, and in 2.6% the aneurysm will rupture (Stather).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Users may find it helpful to read Chapters 1-3 in “Work Ability,” which can provide a framework for considering the benefits of staying at—or returning to—work. Before and after surgery for an AAA, contact sports and activities that require lifting more than 25 pounds or require any significant straining should be avoided. Associated atherosclerotic cardiovascular disease involving the heart or legs and causing effort angina and / or claudication may limit activity or require work accommodations in addition to those necessitated by an AAA.

Following open surgical aneurysm repair, individuals may be hospitalized for 4 to 7 days. Full recovery may take 6 weeks to 3 months ("Abdominal Aortic Aneurysm"). Recovery from an endovascular stent graft is shorter, with 2 to 3 days of hospitalization; however, the individual will need extra time off for frequent follow-up visits to ensure the graft is functioning normally ("Abdominal Aortic Aneurysm").

Risk: Arterio-vascular risk factors are important to address in this disease. Before any surgical repair, jobs involving very heavy work may contribute to progression if blood pressure markedly elevates with work. After successful repair, no job would lead to increased risk of recurrence.

Capacity: Asymptomatic AAA by definition will not limit physical work capacity, provided blood pressure is adequately controlled during exercise. Capacity in patients with PAD is assessed with treadmill testing. Randomized trials of walking programs have demonstrated that they can increase maximum walking distance by 150%. Supervised programs produce results that are superior to unsupervised programs, and typically 1 to 2 months are required for individuals to notice a benefit from the program (Hyman).

Tolerance: Because an unruptured AAA is asymptomatic, tolerance is not an issue. With PAD of the legs, however, tolerance is highly dependent on the job classification. For individuals in a sedentary occupation, length of disability ranges from 7 to 28 days. If the individual is in a medium-activity occupation, the range is 7 to 42 days. Individuals whose occupational activities require heavy or very heavy physical activity may be indefinitely disabled by AAA. Among 936 reference cases, the median time lost from work was 53 days; less than 1% experienced no lost time on the job, and 6.5% lost more than 6 months. New endovascular techniques can be expected to reduce the recovery time for successful revascularization procedures, but the disease is progressive and may lead to limb loss, particularly in individuals who continue to smoke (Hyman).

Walking programs that increase an individual's ability to walk require that the individual repeatedly walk to pain and then rest. Because of the pain associated with exercise programs, many individuals dislike the programs, and drop-out rates are high (Hyman).

Source: Medical Disability Advisor



Maximum Medical Improvement

180 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • What type of AAA does individual have? Was it ruptured or dissecting?
  • What was the cause of the AAA?
  • Did individual present with a clinical history and symptoms consistent with the diagnosis of AAA?
  • Did individual have symptoms of shock or symptoms suggestive of aneurysm rupture?
  • Was the diagnosis confirmed with a physical exam and diagnostic imaging studies?
  • Was the diagnosis determined promptly?
  • If the diagnosis was uncertain, were other conditions with similar symptoms ruled out?
  • Would individual benefit from consultation with a specialist (cardiologist, vascular surgeon, gastroenterologist)?

Regarding treatment:

  • Was the treatment appropriate for the size and nature of the aneurysm?
  • Was there any unnecessary delay in treatment?
  • Did individual require emergency surgery?

Regarding prognosis:

  • Based on the size of the aneurysm and the presenting symptoms (rupture vs. nonrupture), what was the expected outcome?
  • Does individual have any comorbid conditions that may affect surgical risk or ability to recover?
  • Did individual have any complications that may affect recovery and prognosis?

Source: Medical Disability Advisor



References

Cited

"Abdominal Aortic Aneurysm." VascularWeb. Feb. 2011. Society for Vascular Surgery. 18 Apr. 2014 <http://www.vascularweb.org/vascularhealth/Pages/abdominal-aortic-aneurysm.aspx>.

Davies, Mark, John Byrne, and John S. Harvey. "Clostridial Infection of the Abdominal Aorta." Journal of the American College of Surgeons 197 2 (2003): 331-331. MD Consult. Elsevier, Inc. 6 Oct. 2009 <http://home.mdconsult.com/das/journal/view/40781768-2/N/13925091?sid=279058461&source=MI>.

Filardo, G., et al. "Immediate Open Repair versus Surveillance in Patients with Small Abdominal Aortic Aneurysms: Survival Differences by Aneurysm Size." Mayo Clinic Proceedings 88 (2013): 910-919.

Go, A. S. , et al. "Heart Disease and Stroke Statistics--2013 Update: A Report from the American Heart Association." Circulation 127 (2013): e6-e245.

Hellman, David B., D. J. Grand, and J. A. Freischlag. "Inflammatory Abdominal Aortic Aneurysm (Abstract)." JAMA 297 (2007): 395-400.

Hope, M. D., and T. A. Hope. "Functional and Molecular Imaging Techniques in Aortic Aneurysm Disease." Current Opinion in Cardiology 28 (2013): 609-618.

Karkos, C. D., et al. "Abdominal Aortic Aneurysm: The Role of Clinical Examination and Opportunistic Detection." European Journal of Vascular and Endovascular Surgery 19 (2000): 299-303.

Kent, K. C. "Screening for Abdominal Aortic Aneurysm: A Consensus Statement." Journal of Vascular Surgery 39 (2004): 267-269.

Kochanek, K. D., and S. L. Murphy. "Deaths: Final data for 2009." National Vital Statistics Reports 60 3 (2011):

Lederle, F. A. "The Rise and Fall of Abdominal Aortic Aneurysm." Circulation 124 (2011): 1097-1099.

Lederle, F. A., et al. "The Aneurysm Detection and Management Study Screening Program: Validation Cohort and Final Results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators." Archives of Internal Medicine 160 (2000): 1425-1430.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Murphy, S. L., et al. "Deaths: Final data for 2010. National vital statistics reports." NCHS Advance Data 61 4 (2010): None.

Pande, R. L., and J. A. Beckman. "Epidemiology and Prognosis of Aortic Aneurysms." Vascular Medicine: A Companion to Braunwald's Heart Disease. Eds. Mark A. Creager, Joshua A. Beckman, and Joseph Loscalzo. W.B. Saunders, 2012. None-None.

Pearce, William H. "Abdominal Aortic Aneurysm." eMedicine. Eds. Vincent Lopez Rowe, et al. 12 Mar. 2014. Medscape. 18 Apr. 2014 <http://emedicine.medscape.com/article/1979501-overview>.

Stather, P. W. , et al. "Systematic Review and Meta-Analysis of the Early and Late Outcomes of Open and Endovascular Repair of Abdominal Aortic Aneurysm." British Journal of Surgery 100 (2013): 863-872.

Sweeting, M. J., et al. "Meta-Analysis of Individual Patient Data to Examine Factors Affecting Growth and Rupture of Small Abdominal Aortic Aneurysms." British Journal of Surgery 99 (2012): 655-665.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

United States Preventive Services Task Force. "Screening for Abdominal Aortic Aneurysm: Recommendation Statement." Annals of Internal Medicine 142 (2005): 198-202.

Vilalta, G., et al. Biomechanical Approach to Improve the Abdominal Aortic Aneurysm (AAA) Rupture Risk Prediction, Aneurysm. InTech, 2012. In Tech Open. 29 Aug. 2012. InTech. 18 Apr. 2014 <http://www.intechopen.com/books/aneurysm/biomechanical-approach-to-improve-the-abdominal-aortic-aneurysm-aaa-rupture-risk-prediction>.

General

Lederle, Frank A. , J. A. Freischlag, and Tassos C. Kyriakides. "Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm: A Randomized Trial." JAMA 302 14 (2009): 1535-1542.

Source: Medical Disability Advisor






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