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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.

Arthritis, Rheumatoid


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Rehabilitation | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
710.2 - Diffuse Diseases of Connective Tissue, Sicca Syndrome; Sjögrens Disease; Keratoconjunctivitis Sicca (Sicca Syndrome)
714.0 - Rheumatoid Arthritis; Arthritis or Polyarthritis: Atrophic, Rheumatic (Chronic)
714.2 - Other Rheumatoid Arthritis with Visceral or Systemic Involvement; Rheumatoid Carditis

Related Terms

  • Chronic Inflammatory Arthritis
  • Proliferative Arthritis
  • RA
  • Systemic Arthritis

Overview

Image Description:
Rheumatoid Arthritis - A profile of the left hand is shown, highlighting the knuckle or middle joint of the first finger. Two close-ups of the highlighted joint reveal 1) a normal finger joint, and 2) a finger joint with markedly inflamed synovial tissue in the joint space.
Click to see Image

Rheumatoid arthritis (RA) is a chronic, inflammatory, multisystem autoimmune disease that targets the thin membrane (synovium) that lines the joints. Peripheral joints such as the wrists, knees, shoulders, hands and feet are most commonly affected. Although individuals of any age can present with RA, the usual age of onset is between 25 and 50 with a peak in the 40s and 50s.

RA develops when the immune system malfunctions, producing antibodies and immune complexes that attack healthy joint tissue. The result of this exaggerated immune response is thickening of synovial tissue and narrowing of the joint space. This leads to marked inflammation (synovitis) and tissue injury characterized by pain, stiffness, swelling, redness, and heat in and around affected joints. RA is usually symmetrical (i.e., affecting the same joints on both sides of the body simultaneously). Uncontrolled immune system inflammatory response can lead to total joint destruction and deformities. Unlike osteoarthritis (OA), systemic symptoms such as fever, weight loss, anemia, and malaise or weakness may be present, and joint destruction can become far more severe than in osteoarthritis. RA can also affect the major organ systems including the heart (pericarditis), lungs (interstitial lung disease, pleuritis), liver (hepatitis), eyes (dryness, inflammation of the sclera), blood vessels (vasculitis) and skin (nodules and ulcerations).

In 1987, the American College of Rheumatology established diagnostic criteria for the classification of rheumatoid arthritis. These include the presence of four of the following: (1) morning stiffness in and around joints that lasts for longer than one hour, (2) arthritis (pain and inflammation) with swelling of three or more joints simultaneously, (3) at least one of the joints referred to in (2) must be in the hand, (4) symmetric arthritis with simultaneous involvement of the same joint bilaterally, (5) rheumatoid nodules over bony prominences or near joints, (6) positive serum rheumatoid factor (RF), and (7) x-ray changes typical of RA. The first four criteria must have been present for a minimum of 6 weeks.

While the cause(s) of RA is remains unknown, several factors may play a role in disease development. These include a hyper-reactive immune system, association with specific inherited genes and acquired gene defects, hormonal factors, environmental exposures, and previous viral or bacterial infection.

Incidence and Prevalence: Prevalence of RA in both the US and globally is approximately 1% (King; Firestein); at any given time approximately two million individuals in the US are affected by RA ("Comparative Effectiveness").

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors include female sex (the female to male ratio is 3:1) (King; Mercier), and genetic factors (the presence of specific tissue antigens such as class II MHC [major histocompatibility antigen], and human leukocyte antigens [HLA subgroups]).

Source: Medical Disability Advisor



Diagnosis

History: The onset of RA is usually gradual. The most common symptom is symmetrical joint stiffness in the morning that lasts more than 1 hour. Individuals may also complain of fatigue, unexplained fever, malaise, weakness, loss of appetite (anorexia), weight loss, and dry, sensitive eyes. There may be a family history of rheumatoid arthritis or other autoimmune connective tissue disease (i.e., fibromyalgia, lupus erythematosis). Some individuals may report having had rheumatic fever during childhood.

Physical exam: The exam may reveal joint swelling with warm, reddened areas, tenderness to touch, and decreased range of motion. Walking and rising from a seated position may be difficult and grip strength may be markedly diminished. Joints may become deformed as the disease progresses. In more advanced stages, subcutaneous nodules develop in about 20% of cases. Other systemic manifestations may include spleen enlargement (splenomegaly) and carpal tunnel syndrome.

Tests: Laboratory tests, which are helpful in making the diagnosis, include serum rheumatoid factor (positive in about 70-90% of RA cases), erythrocyte sedimentation rate (ESR, a non-specific test for inflammation in the body which is elevated in 90% of RA cases), C-reactive protein (another indicator of inflammation), antinuclear antibodies (ANA, present in 20-30% of individuals with RA) and a positive anti-cyclic citrullinated peptide (CCP antibody). Synovial fluid analysis (aspirated from joint space with a needle and syringe) can reveal antibodies and certain types of immune system cells present in RA. The presence of crystal or bacteria in joint fluid suggests other diagnoses. Because RA is a progressive disease, the typical x-ray findings of joint space narrowing, bony erosion and deformities occur in more advanced stages. Serial x-rays can document changes over time and are helpful in monitoring disease progression and treatment efficacy. Bone densitometry (DEXA scan) is a useful diagnostic tool for osteoporosis, a major comorbidity with RA. MRI of affected joints is a sensitive technique for detection of erosions during the early stages of the disease.

Source: Medical Disability Advisor



Treatment

Treatment for RA has changed dramatically and newer medications can help prevent joint damage. The goal of RA treatment is to control synovitis and thus prevent joint damage and disability. Optimal management involves a combination of nonpharmacological therapy (i.e., rest, exercise, stress reduction, diet modification, psychotherapy or counseling, massage, and physical therapy) and drug therapy. Although regular rest is recommended and complete bed rest may be indicated during flare-ups (disease exacerbations), individuals with RA respond favorably to gentle exercise such as walking, yoga and stretching exercises.

Drugs are prescribed for pain management (analgesia), to control inflammation, and to suppress the immune response. Nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), which include cyclooxygenase-2 (COX-2) inhibitors (celecoxib), provide important symptomatic relief of pain and inflammation, but do not alter the long-term course of the disease.

There has been a growing emphasis on early diagnosis and intensive treatment since joint damage occurs early in the course of the disease. Disease-modifying antirheumatic drugs (DMARDs) are a diverse group of therapeutic agents that can slow disease progression. Some examples of DMARDs are methotrexate, sulfasalazine, and hydroxychloroquine. Biological agents are man-made analogs of naturally occurring molecules that interfere with joint inflammation and destruction. Leflunomide inhibits pyrimidine synthesis. Tumor necrosis factor (TNF) antagonists (etanercept, infliximab, adalimumab) inhibit TNF, a mediator of joint inflammation. Another class of biological agents (abatacept, rituximab) act by inhibiting the interleukin-1 receptor. Combinations of DMARDs and biological agents are used to delay radiologic progression of disease and achieve remission. Medications used to treat RA may have serious side effects so regular monitoring is necessary.

Injections of corticosteroids into affected joints or short-term use of oral corticosteroids may provide relief for acute flare-ups, but are seldom used on a continuing basis because of significant long-term toxicity

Splinting of inflamed joints is sometimes employed to decrease synovitis, prevent deformity, and improve limb function. Surgical treatment, such as to remove synovial tissue (synovectomy), repair joints (arthroplasty), or replace joints, is reserved for the most severe cases in which joints have been completely destroyed and mobility is severely compromised.

Source: Medical Disability Advisor



Prognosis

RA is a chronic, progressive disease. In the most advanced stages, affected joints can become grossly deformed and dysfunctional, tendons can rupture, and bone can be destroyed. Most individuals experience remissions and flare-ups (exacerbations) of the disease over time. Up to 75% of individuals with RA improve symptomatically with treatment, but 10% become severely disabled, even with full treatment (Beers). Research studies have shown that life expectancy is reduced in patients with RA by 3 to 18 years.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Emergency Medicine Physician
  • Infectious Disease Internist
  • Internal Medicine Physician
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Rheumatologist

Source: Medical Disability Advisor



Rehabilitation

Rheumatoid arthritis is a progressive, chronic, systemic disease that may involve numerous joints in the body. The focus of rehabilitation is to preserve function and to control pain. Rehabilitation will be based upon the stage of the disease, such as an instance of acute flare-up or of ongoing symptoms.

During an acute flare-up, rehabilitation must, in conjunction with pharmacological treatment (Vliet Vlieland), address pain control through the use of modalities such as heat (Robinson). Gentle motion may be initiated with care to avoid an increase of inflammatory symptoms. Attempts should be made to prevent the loss of range of motion and to maintain as much independent function as possible.

Once the acute stage has passed, the therapist begins addressing mobility and strength. The object of all exercise is to maximize independence in all functional activities. Gentle range of motion exercises are taught and progressed to strengthening exercises. These exercises may be performed as part of an aquatic program or in conjunction with another form of heat. Because steroids are commonly used to treat rheumatoid arthritis, and osteoporosis may result from long-term steroid use, a general aerobic conditioning program, including weight bearing exercises, should be incorporated into the rehabilitation program. All exercise progression is gradual with consideration of the individual's tolerance and the underlying disease.

Occupational therapy may also be necessary to address activities of daily living. A home assessment might be indicated to ascertain that the environment is optimal for the individual's needs. The occupational therapist may recommend assistive devices for common daily tasks and may also assess the need for devices for joint protection such as splints or other supportive equipment (Egan; Steultjens).

An ergonomic evaluation may be beneficial to modify the workstation so that the individual may be able to maintain his or her employment status.

Because individuals may experience depression if their activities become restricted as a result of exacerbations of this disease, counseling or a support group might be needed. Individuals may also benefit from the experience of other individuals with similar needs (Riemsma).

Additional information may provide insight into the rehabilitation needs of these individuals (Oh).

FREQUENCY OF REHABILITATION VISITS
ClassificationSpecialistTopicVisit
Nonsurgical Physical or Occupational TherapistArthritis, RheumatoidUp to 24 visits within 12 weeks
Note on Nonsurgical Guidelines: It is quite difficult to pinpoint the rehabilitation needs of individuals with rheumatoid arthritis. Some contributing factors include the point of diagnosis, number of involved joints, acuteness of illness, recurrence, response to medication, joint integrity, anatomical involvement and progression of disease.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Components of multiple organ systems may be affected by RA including the eyes (dryness, scleritis), lungs (interstitial lung disease, pleuritis, pleural effusions resulting in shortness of breath), blood (anemia), blood vessels (vasculitis), heart (carditis, pericarditis, pericardial effusions), nerves (neuritis, carpal tunnel syndrome), and muscles. Many drug therapies are immunosuppressive and may result in secondary organ involvement, particularly liver conditions. If joints of the cervical spine are affected, individuals may develop sensory loss, severe shoulder and neck pain, abnormal neurological sensations such as numbness (paresthesia), and arm weakness. Depending on how severely the spinal cord is affected, individuals may develop vertigo, fainting episodes, loss of bowel/bladder control or difficulty in swallowing, all of which would require immediate medical intervention. Depression, anger, loss of self-esteem, fatigue, and weight loss are also seldom recognized complications of RA.

Source: Medical Disability Advisor



Factors Influencing Duration

Although some individuals have mild symptoms that resolve, most people experience progressive disease over the course of their lifetime. The individual's age, the rate of disease progression, the severity of the disease, which joints and how many joints are involved, organ system involvement, the response to treatment, and the pattern of remissions and exacerbations all affect the length of disability.

New onset cases with today's disease modifying treatment will usually be able to stay at work, while cases with onsets greater than 10 years ago may have enough destructive arthritis to be permanently unable to do heavy work.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions and accommodations depend on the joints involved. Individuals must be able to stop activity with the onset of pain, fatigue, or increased swelling. Individuals should avoid stooping, lifting, and standing for long periods, and should be allowed a change in position every 20 to 30 minutes. Individuals should avoid heavy lifting, high grip force, and repetitive motion. Adaptive devices should be used to avoid tight gripping or pinching. Evaluation of safety issues with assistive devices and lessened mobility are necessary. Use of prescribed pain medications may necessitate a review of drug policies. Individuals with RA may have difficulty with jobs that require either constant physical work or very sedentary work.

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:

  • Does individual have symptoms consistent with diagnosis of RA (morning joint stiffness lasting longer than 2 hours, symmetric joint swelling and inflammation, fatigue, loss of appetite, unexplained fever, and weakness)?
  • Does individual have a family history of RA?
  • Has diagnosis of RA been confirmed through lab tests, synovial fluid analysis, x-rays?
  • Have conditions with symptoms similar to RA (such as osteoarthritis, gout, reactive arthritis, etc.) been ruled out?

Regarding treatment:

  • Is individual enrolled in a comprehensive treatment plan that allows for optimization of nonpharmacological and pharmacological therapies?
  • Does individual receive physical therapy?
  • Is individual taking medications as prescribed?
  • If individual is experiencing side effects, have alternate drug options been tried?
  • Have conservative measures been effective at reducing the symptoms and maintaining strength and mobility?

Regarding prognosis:

  • Based on the severity of the disease and the general health of individual, what is the expected outcome?
  • Has individual experienced any associated conditions or complications (such as eye dryness, pleurisy, anemia, vasculitis, neuritis, depression, fatigue, weight loss, etc) that could impact recovery and prognosis?
  • Is individual receiving counseling or treatment for the depression, anger and loss of self-esteem that can accompany the diagnosis of a chronic illness?
  • Does individual have any underlying conditions (e.g., diabetes mellitus, osteoporosis, osteoarthritis, etc.) that may impact recovery?

Source: Medical Disability Advisor



References

Cited

"Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis in Adults." Agency for Healthcare Research and Qualtiy. 19 Nov. 2007. U.S. Department of Health and Human Services. 29 Dec. 2008 <http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=rr&DocID=70&ProcessID=14>.

Beers, Mark H., and Robert Berkow, eds. "Rheumatoid Arthritis." The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck and Company, Inc., 1999. Merck. Merck & Co., Inc. 29 Oct. 2004 <http://www.merck.com/mrkshared/mmanual/section5/chapter50/50a.jsp>.

Egan, M., et al. "Splints/Orthoses in the Treatment of Rheumatoid Arthritis." Cochrane Database of Systematic Reviews 1 (2003): CD004018. National Center for Biotechnology Information. National Library of Medicine. 18 Jul. 2008 <PMID: 12535502>.

Firestein, G. S. "Etiology and Pathogenesis of Rheumatoid Arthritis." Kelley's Textbook of Rheumatology. Eds. Edward Harris, et al. 7th ed. Philadelphia: Elsevier, Inc., 2005.

King, Randall W., and Richard Worthington. "Arthritis, Rheumatoid." eMedicine. Eds. Edward Bessman, et al. 13 Jul. 2006. Medscape. 24 Nov. 2008 <http://emedicine.com/emerg/topic48.htm>.

Mercier, L. R. "Arthritis, Rheumatoid." Ferri's Clinical Advisor: Instant Diagnosis and Treatment. Ed. Fred Ferri. 2004 ed. St. Louis: Mosby, Inc., 2004. 98-100.

Oh, T. H., et al. "Rehabilitation of Orthopedic and Rheumatologic Disorders. 2. Connective Tissue Disease." Archives of Physical and Medical Rehabilitation 81 2 Suppl 1 (2000): S60-S66. National Center for Biotechnology Information. National Library of Medicine. 18 Jul. 2008 <PMID: 10721762>.

Riemsma, R. P., et al. "Patient Education for Adults with Rheumatoid Arthritis." Cochrane Database of Systematic Reviews 2 (2003): CD003688. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 12804484>.

Robinson, V., et al. "Thermotherapy for Treating Rheumatoid Arthritis." Cochrane Database of Systematic Reviews 1 (2002): CD002826. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 12076454>.

Steultjens, E. M., et al. "Occupational Therapy for Rheumatoid Arthritis." Cochrane Database of Systematic Reviews 1 (2004): CD003114. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 14974005>.

Vliet Vlieland, T. P. "Rehabilitation of People with Rheumatoid Arthritis." Best Practice & Research Clinical Rheumatology 17 5 (2003): 847-861. National Center for Biotechnology Information. National Library of Medicine. 3 Dec. 2004 <PMID: 12915161>.

General

Klippel, John, ed. Primer on the Rheumatic Diseases. 13th ed. New York: Springer, 2008.

Oliver, Alyce M., and William St. Clair. "Rheumatoid Arthritis: Treatment and Assessment." Primer on the Rheumatic Diseases. Ed. John Klippel. 13th ed. New York: Springer, 2008. 133-141.

Smith, Howard R. "Rheumatoid Arthritis." eMedicine. Eds. Kristine M. Lohr, et al. 24 May. 2006. Medscape. 24 Nov. 2008 <http://emedicine.com/med/topic2024.htm>.

Tehlirian, Christopher V., and Joan M. Bathon. "Rheumatoid Arthritis: Clinical and Laboratory Manifestations." Primer on the Rheumatic Diseases. Ed. John Klippel. 13th ed. New York: Springer, 2008. 114-121.

Source: Medical Disability Advisor