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.

Cerebrovascular Disease


Related Terms

  • Cerebral Ischemia
  • Cerebrovascular Arteriosclerotic Disease
  • Cerebrovascular Disorder
  • Cerebrovascular Event
  • Stroke
  • Transient Ischemic Attack

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Infectious Disease Internist
  • Internal Medicine Physician
  • Neurologist
  • Neurosurgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical or Occupational Therapist
  • Psychiatrist
  • Pulmonologist
  • Radiologist
  • Speech Therapist

Comorbid Conditions

  • Chronic medical conditions
  • Diabetes
  • Heart disease
  • Lupus
  • Neurologic diseases
  • Obesity

Factors Influencing Duration

Factors influencing the duration of recovery include the individual's age and response to treatment, job duties, whether the individual suffers a stroke as a result of cerebrovascular disease, and the severity and complications of the stroke.

Medical Codes

ICD-9-CM:
436 - Cerebrovascular Disease, Acute, But Ill-defined
437.0 - Cerebrovascular Disease, Other and Ill Defined; Cerebral Atherosclerosis
437.1 - Cerebrovascular Disease, Other and Ill Defined; Other Generalized Ischemic Cerebrovascular Disease
437.2 - Cerebrovascular Disease, Other and Ill Defined; Hypertensive Encephalopathy
437.3 - Cerebrovascular Disease, Other and Ill Defined; Cerebral Aneurysm, Non-ruptured
437.9 - Cerebrovascular Disease, Other and Ill Defined; Cerebrovascular Disease, Unspecified; Cerebrovascular Disease or Lesion NOS

Overview

Cerebrovascular disease is a group of conditions that affect blood supply to the brain; the term includes disorders such as transient ischemic attack (TIA), ischemic or hemorrhagic stroke, and cerebrovascular anomalies such as aneurysms and arteriovenous malformations (AVMs). Individuals with cerebrovascular disease have either suffered a sudden decrease in oxygen supply to the brain (stroke) or are at risk to do so.

A transient ischemic attack (TIA), also called a mini-stroke, is a temporary (less than 24 hours) episode of neurologic dysfunction caused by ischemia in a particular brain region, and may be a warning of stroke. Currently it is recommended that TIAs be treated like strokes, with similar evaluation and diagnostic tests, since they frequently go on to become strokes with permanent impairment. However, stroke is often the first sign that individuals have cerebrovascular disease.

Cerebrovascular disease is the most frequent cause of stroke, which occurs when the constant supply of oxygen and nutrients to the individual's brain is cut off because a blood vessel either is blocked (ischemic stroke) or starts to leak (hemorrhagic stroke), causing bleeding into the brain. That part of the brain that is cut off from its blood supply can rapidly deteriorate due to death of nerve cells.

Cerebrovascular disease is also a common cause of progressive memory loss and intellectual deterioration due to decreased blood flow and oxygen supply to the brain (vascular dementia).

Incidence and Prevalence: Cerebrovascular disease is the most common cause of neurologic disability in industrialized countries. Each year about 130,000 Americans experience a stroke (CDC). Stroke is the fourth leading cause of death and the tenth leading cause of disability in the US (CDC). The most common types of stroke are ischemic (87%), with the remaining strokes hemorrhagic (13%) (Go). About 15% of all strokes are preceded by a TIA (Go).

Blacks have a higher prevalence of hypertension, diabetes, obesity, smoking, and sickle cell anemia leading to a prevalence of stroke almost twice that in Caucasian populations, with 3.9% of blacks and 2.4% of Caucasians affected (Go). The incidence of stroke in black males aged 45 to 54 is 9.7 per 1,000 and 7.2 per 1,000 black females; the incidence of stroke in Caucasian males and females aged 45 to 54 is 2.4 per 1,000 (Go). By age 65, the incidence of stroke in black males and females increases to 13.1 per 1,000 and 10.0 per 1,000 respectively, and stroke incidence in Caucasian males is 6.1 per 1,000 and in Caucasian females 4.8 per 1,000 (Go).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals with cardiovascular disease, high blood lipid concentrations (hyperlipidemia), high blood pressure (hypertension), diabetes, and irregular heartbeat (atrial fibrillation) are at higher risk for cerebrovascular disease as well as those with sleep apnea and elevated levels of homocysteine. Rare genetic disorders may also increase risk of cerebrovascular disease and stroke. Risk of a first or subsequent stroke is lowered in individuals taking blood pressure-lowering drugs (antihypertensives) and blood cholesterol-lowering drugs (including statins).

Men have a higher risk for stroke than women. Most strokes occur in adults over the age of 55, and the risk of stroke increases with each decade of age. Lifestyle risk factors for stroke are high cholesterol, obesity, cigarette smoking, cocaine use (the most common cause of stroke in individuals under age 55), and heavy use of alcohol (Go; Treadwell).

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report episodes of fainting (syncope), dizziness, confusion, loss of consciousness, headache, nausea, numbness, weakness, paralysis of one side of the body, visual symptoms, difficulty in speaking or in understanding speech, trouble walking, and loss of balance or coordination. When an individual reports suffering the worst headache of his or her life, this should raise a red flag for the diagnosis of bleeding into the brain (subarachnoid hemorrhage). Their medical history may include reports of risk factors such as hypertension, heart disease, hyperlipidemia, high cholesterol (hypercholesterolemia), smoking, inflammation of the medium-sized arteries supplying the head and eyes (arteritis), trauma, increased red blood cells (polycythemia), and sickle cell disease.

Physical exam: An individual with cerebrovascular disease who is at risk for stroke may be obese or have hypertension. Clogged arteries (atherosclerosis) may be detected by decreased pulsation when the physician feels (palpates) the peripheral arteries, or by abnormal sounds when listening to a stethoscope (auscultation) placed over the artery (bruit). A bruit over the main artery in the neck (carotid artery) may suggest that the vessel is narrowed and that the individual is at increased risk for a stroke, but as blood flow decreases farther in the narrowed artery, the bruit may no longer be audible. The heart should be examined carefully for abnormal sounds or rhythm that could indicate heart disease. The individual who has suffered a stroke may have neurologic signs such as weakness or numbness on one side of the body, increased or asymmetrical reflexes, abnormal reflexes suggesting involvement of motor pathways, visual field cut, abnormal eye movements or reflexes, decreased or asymmetrical gag reflex, droop of one side of the face, difficulty speaking (expressive aphasia) or understanding spoken speech (receptive aphasia), slurred speech (dysarthria), or coordination or balance difficulties. The pattern of neurologic abnormalities helps the physician determine the location of the stroke.

Tests: Computed tomography (CT) and magnetic resonance imaging (MRI) are radiology tests that give pictures of the brain structure. Carotid ultrasound or transcranial ultrasound (blood flow tests) help to find any blocks in the passage of blood to and through the brain. A more detailed look at the arteries requires angiography, in which a catheter is inserted into a large leg artery (femoral artery) and threaded back toward the neck. Arteries supplying the brain can then be visualized by x-rays when a special dye is injected through the catheter. Blood samples are also used to diagnose diabetes, heart attack (myocardial infarction), coagulation abnormalities, and hyperlipidemia and/or hypercholesterolemia. Electrocardiogram (ECG) helps to determine whether the individual has suffered a myocardial infarction, which frequently accompanies stroke. Electroencephalogram (EEG) may help diagnose stroke through the pattern of brain wave activity, and should be done if the individual is suffering seizures after a stroke. Spinal tap (lumbar puncture) may be needed to diagnose bleeding into the brain (subarachnoid hemorrhage), although if blood is obvious on brain CT, a spinal tap is unnecessary and should be avoided. A transesophageal echocardiogram (TEE) should be done to look for clot formation in the heart that may have caused the stroke.

Source: Medical Disability Advisor



Treatment

Treatment for an individual with cerebrovascular disease is aimed at preventing a first or subsequent stroke, and may include drugs that prevent blood clots from forming (anticoagulants and thrombolytics), drugs that lower blood pressure (angiotensin-converting-enzyme [ACE] inhibitors, diuretics, calcium channel blockers, antihypertensives, and beta-blockers), and drugs for lowering blood cholesterol, such as the statins. Surgery (carotid endarterectomy) is sometimes also performed to unclog a carotid artery so that blood can flow freely to the brain and a stroke may be prevented.

Suspected stroke, also called a "brain attack" to emphasize its similarities to heart attack, is a true medical emergency. At the first appearance of warning signs of a stroke, 911 should be called and the individual should go immediately to the hospital by ambulance, preferably to a stroke center skilled in the tissue plasminogen activator (t-PA) protocol. This drug can break up blood clots in brain arteries and reverse or minimize damage to the brain, but it must be given within 3 hours of onset of stroke symptoms. For this reason, it is critical that no time be wasted in getting to the hospital, in being seen by the stroke team, and in having the brain CT and other tests done before the drug can be given. Obtunded or comatose individuals may require mechanical ventilation, and intracranial pressure monitoring and treatment of cerebral edema may be necessary.

Individual who smoke must quit the habit; other lifestyle changes that may be helpful include a low-fat diet rich in fruits and vegetables (according to the recommendations of the American Dietetic Association) and a regular exercise program. Individuals taking anticoagulants should avoid foods rich in vitamin K because they will diminish the drugs' effects.

Source: Medical Disability Advisor



Prognosis

The outcome varies with the extent of disease and brain damage at the time of treatment and other chronic underlying medical complications. The individual who was healthy and had no neurologic symptoms before suffering a mild stroke may completely recover and lead a normal life after following the prescribed treatment. The individual who has suffered a massive stroke may be permanently paralyzed on one side of the body and no longer be able to speak. The individual who has suffered more than one stroke may be completely paralyzed and may have his or her life shortened considerably. Recovery of any movement or speech may be very limited. Each year, nearly 800,000 Americans suffer a stroke; 130,000 die from it (Go).

If carotid endarterectomy is performed, the individual may avoid a stroke. Recovery from this surgery should be complete within 6 weeks, and the individual may be able to return to his or her normal activities, including work.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation includes a determined effort to decrease stroke risk, which may include drugs to lower blood lipids and high blood pressure, and a program of a healthy diet, regular exercise, no smoking, and moderate alcohol use. When a stroke causes persistent weakness, numbness, or coordination difficulties, physical and occupational therapy are indicated to prevent joint stiffness and immobility (contractures) and to allow maximal independence in walking and in activities of daily living. The length of therapy depends on the severity of the stroke. An individual who has suffered a mild stroke may only need 12 visits. Speech therapy may be indicated if the individual suffers from difficulty in speaking, understanding speech, or swallowing. Respiratory therapy may be indicated if the individual is bedridden and has trouble breathing or clearing secretions, or if pneumonia is present. Vocational rehabilitation may be needed to facilitate return to work. Support groups and counseling may help individuals and families adjust to their disability and lifestyle changes. Social work intervention may be needed to facilitate proper placement, home care, or home modifications.

Source: Medical Disability Advisor



Complications

Neurologic complications of stroke include permanent brain damage, with possible impairments of weakness, paralysis, numbness, expressive aphasia, receptive aphasia, vision problems, difficulty swallowing, dysarthria, seizures, and problems with walking or coordination. Perhaps because of these deficits or because of involvement of certain brain pathways, the individual who has suffered a stroke frequently becomes depressed, especially if the stroke involves the left half (hemisphere) of the brain. A single large stroke or many small strokes can cause progressive deterioration in memory, intellect, and personality (vascular or multi-infarct dementia). Strokes can be fatal if vital brain centers controlling the heart or respiration are involved, or if the individual suffers a myocardial infarction along with the stroke. If swallowing or gag reflex is affected, the individual may choke on secretions that then enter the lungs, where they can give rise to pneumonia (aspiration pneumonia). Immobility and increased clotting factors present in the blood following a stroke increase the risk of blood clots in the legs (deep venous thrombosis [DVT]) that can then dislodge and travel to the lungs (pulmonary embolus). Individuals who are paralyzed from a stroke may develop immobility of joints (contractures) or bedsores (pressure ulcers or decubitus ulcers), especially if physical therapy or nursing care is inadequate.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

To prevent a stroke, an individual needs to incorporate frequent exercise and a healthy diet, including plenty of fruits and vegetables, into his or her daily life. These elements should be part of the work environment; for example, work should include frequent walking and light lifting. Once an individual has had a stroke, restrictions and accommodations depend on the extent and nature of the disability, if the individual is able to return to work at all. For example, the workplace may need to be wheelchair-accessible, and individuals with slurred speech may no longer be able to answer telephones.

Risk: Cerebrovascular disease without a stroke would not be expected to have any job risk associated with it. Treatment of underlying risk factors would be important. If a heavy demand job leads to uncontrolled hypertension, consideration should be given to medication changes.

Capacity: Cerebrovascular disease without a stroke would not be expected to have any impact on capacity.

Tolerance: Cerebrovascular disease without a stroke would not be expected to have any impact on tolerance. Concerns over the underlying risk factors should be addressed with the individual's physician.

Source: Medical Disability Advisor



Maximum Medical Improvement

360 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:

  • Has individual had warning signs of a stroke? Has individual had a stroke? TIA?
  • Does individual have hypertension, heart disease, or diabetes? Does individual smoke cigarettes?
  • Is individual obese?
  • Does individual have hyperlipidemia? Hypercholesterolemia
  • Does individual have arteritis, trauma, polycythemia, or sickle cell disease?
  • Has individual had a CT and MRI? Angiography? Blood tests? ECG? EEG?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Was individual taken by ambulance to the hospital at the first sign of TIA or stroke?
  • Did individual receive t-PA?
  • Is individual on medication to lower blood pressure? Lower cholesterol? To prevent blood clots?
  • Has individual stopped smoking and adopted a low-fat diet? Does individual exercise regularly?
  • Was surgery necessary to unclog the artery?

Regarding prognosis:

  • Does individual actively participate in a rehabilitation program that includes physical and occupational therapy as well as education in diet?
  • Did individual need speech therapy? Can individual safely swallow?
  • Does individual actively participate in a home exercise program?
  • If needed, is individual enrolled in vocational rehabilitation?
  • Has individual (and family, if needed) attended support groups or sought counseling?
  • Does individual have any conditions that may affect ability to recover?
  • What was the severity of individual's stroke and complications?
  • Does individual have a heart healthy diet?

Source: Medical Disability Advisor



References

Cited

"47.5 Million U.S. Adults Report a Disability; Arthritis Remains Most Common Cause." CDC. 21 Jun. 2011. Centers for Disease Control and Prevention. 8 May 2014 <http://www.cdc.gov/features/dsadultdisabilitycauses/>.

"Leading Causes of Death." CDC. 30 Dec. 2013. Centers for Disease Control and Prevention. 8 May 2014 <http://www.cdc.gov/nchs/fastats/lcod.htm>.

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

Jauch, Edward C. "Ischemic Stroke." eMedicine. Eds. Helmi L. Lutsep, et al. 2 May. 2014. Medscape. 8 May 2014 <http://emedicine.medscape.com/article/1916852-overview>.

Singh, Niten. "Atherosclerotic Disease of the Carotid Artery." eMedicine. Eds. Vincent Lopez Rowe, et al. 27 Mar. 2014. Medscape. 8 May 2014 <http://emedicine.medscape.com/article/463147-overview>.

Treadwell, S. D. , and T. G. Robinson. "Cocaine Use and Stroke." Postgraduate Medical Journal 83 (2007): 389-394.

Source: Medical Disability Advisor






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