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.

Cervicobrachial Syndrome


Related Terms

  • Brachial Plexopathy
  • Cervical Rib Syndrome
  • Cervicobrachial Myofascial Pain Syndrome
  • Cervicobrachial Neuralgia
  • Cervicobrachial Neurovascular Compression Syndrome
  • Cervicobrachialgia
  • Costoclavicular Syndrome
  • First Thoracic Rib Syndrome
  • Shoulder-hand Syndrome
  • Thoracic Outlet Compression Syndrome
  • Thoracic Outlet Syndrome
  • TOS

Differential Diagnosis

Specialists

  • Chiropractor
  • Clinical Psychologist
  • Neurologist
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Psychiatrist
  • Rheumatologist

Comorbid Conditions

  • Anemia
  • Autoimmune diseases (e.g., rheumatoid arthritis, lupus)
  • Cancer (tumors, masses)
  • Fibromyalgia
  • Hormonal imbalances (thyroid, estrogen)
  • Infection
  • Inflammatory diseases
  • Mechanical and postural disorders (e.g., short leg, hyperlordosis, hypolordosis)
  • Neck pain
  • Nerve entrapment or impingement at other sites
  • Nutritional deficiencies (e.g., B vitamins, folate, vitamin C)
  • Obesity
  • Psychiatric disorders
  • Sleep disorder

Factors Influencing Duration

Factors influencing length of disability include severity of symptoms, the individual's job requirements, underlying psychological problems or sleep disturbance associated with the disability, and lack of adequate coping skills. Some individuals may have persistent pain for years, but generally disability may be brief and temporary. Work ability is determined largely by psychosocial tolerance of symptoms and not by risk of complications or lack of capacity. Inadequate response to treatment for chronic pain and accompanying psychological issues or sleep disturbance may influence duration.

Medical Codes

ICD-9-CM:
723.3 - Cervicobrachial Syndrome (Diffuse)

Overview

Cervicobrachial syndrome is a nonspecific term describing some combination of pain, numbness, weakness, and swelling in the region of the neck and shoulder. The term may have originated with Kenneth Aynesworth, who used it to describe cases he felt were thoracic outlet syndrome. These cases included the rare conditions of objectively verifiable vascular compression or neurologic compression due to thoracic outlet syndrome, and the common condition of objectively unexplainable similar symptoms. This diagnosis of objectively unexplainable symptoms was used as a synonym for the symptoms of many workers in the Australian epidemic of “repetitive strain injury” and was a common diagnosis in the earlier Japanese epidemic of neck and shoulder symptoms in workers. There is still an ICD-9 code for this diagnosis (723.3), although now more physicians use the codes for shoulder pain and / or neck pain.

The word “syndrome” means a collection of symptoms commonly seen together but for which there is no known explanation. When medical science discovers the cause of a disease or condition, it is renamed. For example, “Down’s syndrome” has been renamed “Trisomy 21” to denote the extra chromosome that causes this condition.

The term “cervicobrachial syndrome” should therefore denote a collection of neck and arm symptoms for which there is no known cause. If a particular patient can be proven to have cervical radiculopathy or vascular compression in the thoracic outlet, then the specific and objectively documented diagnosis should be used.

The term “cervicobrachial syndrome” is used by some physicians to describe symptoms they suspect come from cervical nerve root irritation that cannot be documented, whereas other physicians reserve the term for patients whose symptoms may come from undocumentable thoracic outlet syndrome. Still other physicians use the term as a synonym for “myofascial pain syndrome” with symptoms in the neck and / or shoulder that are believed to arise in muscle.

The definition of “cervicobrachial syndrome” is probably unique to the doctor who uses the term. It may be that an alternate, objectively documentable diagnosis is present, but most often the diagnosis of “cervicobrachial syndrome” refers to symptoms for which there is no proven diagnosis.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may complain of pain and fatigue of the wrist, forearm, shoulders, and neck; a swelling sensation in the hands; pins and needles; and heaviness or numbness of the upper extremity. Pain is increased by activity and relieved by rest. However, it may also increase at night, and individual may report difficulty sleeping. Individuals may have the sensation of wearing gloves when they are not. Headaches may accompany other symptoms. When asked about occupation, individuals may describe being engaged in manual work with continuous, repetitive tasks, including computer keyboard work, writing, manipulating small objects, or moving objects onto conveyor belts. Occupations involving lifting or overhead work may be reported, as well as tasks that require holding the same neck position for extended periods. Physicians will obtain a thorough health history, including prior and current illness and previous trauma, especially trauma resulting in spinal injury.

Physical exam: The arms, shoulders, and neck usually appear normal but are painful to touch, and the neck may be stiff with limited range of motion, particularly on neck extension. Individuals may have poor posture with rounded shoulders and stooped head and neck. Raising the arm (abduction) may increase pain response. Observation of possible asymmetry of the upper chest, including the clavicle, may reveal abnormalities indicative of prior fracture or anatomical defect.

Physical stress tests may be employed to reproduce symptoms, including the Adson maneuver, in which the head is placed in extension and bent to the side while the individual holds his or her breath and the physician observes for symptoms and pulse reduction. Hyperabduction of the arm, or elevated arm stress test (the “stick ’em up” stress test), may also produce symptoms and loss of pulse, indicating TOS. A testing technique called costoclavicular bracing is able to close the space between the clavicle and the first rib, reproducing symptoms of the syndrome. If these physical examination tests are positive, some physicians will change the diagnosis to thoracic outlet syndrome, whereas others will continue to use the cervicobrachial syndrome diagnosis, which to them means thoracic outlet syndrome.

Tests: Radiographic images are taken primarily to rule out objectively verifiable causes for the symptoms. Plain x-rays may also identify first rib abnormalities or the presence of accessory ribs. Current or prior spinal injury or pathology (e.g., cervical root injury, herniated disc, bone spurs) may be evaluated by MRI or CT imaging, including CT myelography. Electrodiagnostic tests (EMG, NCV) are used to identify or rule out nerve damage. Vascular injury or thrombosis may be evaluated by conventional angiography, by magnetic resonance angiography (MRA), or by conventional venography. Doppler ultrasound may be used to identify interrupted blood flow to the involved arm.

Psychological testing and evaluation often reveal psychosocial stressors. Polysomnogram testing may be done to evaluate reported sleep disturbances.

In conclusion, there are no criteria for this diagnosis, since it represents a collection of symptoms for which there is no known cause. If a specific pathologic condition can be documented, this diagnosis should not be used.

Source: Medical Disability Advisor



Treatment

Treatment is conservative and symptomatic. Pain and sleep disorders are relieved with medications. A cervical collar or wrist splints may be used briefly to support the muscles. Physical therapy (e.g., deep heat, ultrasound, electric stimulation, postural correction, strength and endurance exercises) may decrease symptoms and improve function. Individuals should increase daily exercise activity, especially stretching exercises of the neck and shoulder. Spinal manipulation and mobilization combined with progressive active exercise may be helpful. Physical therapy and / or splints are also useful in preventing abnormal and painful positioning of the joints (contractures) that occur when the muscles surrounding the joints become shortened. Improvement in posture may be an important goal of physical therapy and helpful for individuals with postural defects. Mobilization and manipulation procedures sometimes performed by osteopathic physicians are credited with releasing contracted vertebrae and myofascial stress.

Management of chronic pain may include use of muscle relaxants or nonsteroidal anti-inflammatory drugs (NSAIDs), which can reduce pain and the irritability associated with pain, enhancing results of conservative treatment. If vascular compression is identified, some physicians (internists, rheumatologists) may prescribe vasodilators or calcium-channel blockers.

Source: Medical Disability Advisor



Prognosis

Recovery from cervicobrachial syndrome may be complete, partial, or very limited. If the cause of the syndrome is nonspecific, treatment will be less focused, and the outcome will be uncertain. Chronic pain and related disability can be complicated by psychological issues. A better outcome is expected when the diagnostic workup is comprehensive, diagnostic findings are specific for an objectively verifiable disorder (e.g., documented neurogenic TOS, vascular TOS), and bio-psychosocial treatment is provided, combining chronic pain treatment with treatment of psychological issues, sleep disorders, and concomitant chronic illness.

Source: Medical Disability Advisor



Rehabilitation

The primary goals of rehabilitation for cervicobrachial syndrome are to decrease pain and to increase function. Rehabilitation for cervicobrachial syndrome varies with the etiology of the pain, which may be caused by a tumor, infection, or a degenerative or traumatic condition.

The first goal of treatment for cervicobrachial syndrome - the reduction of pain - may be achieved through thermal modalities used in conjunction with pharmacological management (Gross, "Physical medicine modalities"). In contrast to these approaches, immobilization with a soft collar is rarely indicated.

While managing pain, individuals can be instructed in gentle exercises. Initial exercises may include isometrics, stretching, and gentle range of motion. Spinal manual therapy might be beneficial in reducing symptoms when combined with active treatment (Gross, "Manipulation and mobilization"). As a result of the variability in individual response, the treating practitioner must pay careful attention to the individual's tolerance to treatment. Postural training, accordingly, should be initiated as soon as tolerated by the individual.

Once symptoms are relieved and range of motion is restored, therapy should progress to strengthening and stabilization exercises of the neck, shoulders, and upper trunk (Hagberg). Cervical traction has been shown to be beneficial for neck pain when done in conjunction with such exercises. However, traction must be carefully administered to avoid an adverse response. To complement the supervised rehabilitation, the therapist should instruct the individual in a home exercise program. At this time, the therapist should also instruct the individual how to care for and protect the neck from recurrence of symptoms, as well as how to manage recurring symptoms.

An ergonomic evaluation can provide information regarding the avoidance or modification of activities and positions at work that may aggravate the symptoms. Psychological intervention such as cognitive and behavioral pain management may be indicated to support the individual and identify associated factors that may be contributing to the pain (Gross, "Manipulation and mobilization"; Klaber Moffett).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistCervicobrachial Syndrome
Occupational or Physical TherapistUp to 15 visits within 6 weeks
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



Complications

There are no specific complications associated with this condition.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Ergonomic changes in the workplace permit the individual to work more comfortably. They can be as simple as changing the size of a ballpoint pen, providing a chair that takes weight off the forearms, or talking into a telephone headset. Retraining or training in a new job may be helpful for cases that do not respond to treatment. Accommodations that support better posture while working can increase comfort and enhance recovery. Physical therapy is an important component of treatment, and regular time off may be needed to receive therapy. Heavy lifting or repetitive overhead motion may need to be restricted or eliminated.

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 a history of working with prolonged neck postures or manual work with repetitive tasks?
  • Do pain or symptoms increase at night? Does individual have difficulty sleeping? Has the sleep disturbance been addressed by polysomnogram testing or by attempts at treatment?
  • Does individual have observably poor posture? Has poor posture been addressed by a therapist and a home exercise program?
  • Were electrodiagnostic tests performed to rule out nerve damage?
  • Was possible vascular injury or thrombosis evaluated by angiography or venography? Was Doppler ultrasound performed to identify interrupted blood flow to the involved arm?
  • Was diagnosis of cervicobrachial syndrome or thoracic outlet syndrome confirmed by diagnostic tests and consultations?
  • Were other conditions with similar symptoms ruled out? Was evidence found of cervical disc degeneration?
  • Was psychological evaluation done?

Regarding treatment:

  • Is postural correction part of treatment?
  • Has individual completed the recommended course of physical therapy?
  • If not already involved in this form of rehabilitation, would individual benefit from occupational therapy?
  • Is psychological counseling being provided?
  • Does treatment include sleep therapy?
  • Does treatment for chronic pain involve use of medications?

Regarding prognosis:

  • Did individual show any improvement during physical therapy?
  • Has individual’s posture improved noticeably?
  • If outcome was not as expected, what are the extenuating circumstances? How specific was diagnosis?
  • To what extent do symptoms impair function?
  • Has individual been compliant with medications and physical therapy regimen?
  • Does individual need retraining?
  • Does individual have an underlying condition that may affect recovery?
  • Would individual benefit from psychotherapy or psychological counseling?

Source: Medical Disability Advisor



References

Cited

Aynesworth, Kenneth H. "The Cervicobrachial Syndrome." Annuals of Surgery 111 5 (1940): 727-742.

Gross, A. R., et al. "Manipulation and Mobilisation for Mechanical Neck Disorders." Cochrane Database of Systematic Reviews 1 (2004): CD004249. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008 <PMID: 14974063>.

Gross, A. R., et al. "Physical Medicine Modalities for Mechanical Neck Disorders." Cochrane Database of Systematic Reviews 2 (2000): CD000961. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008 <PMID: 10796402>.

Hagberg, M., et al. "Rehabilitation of Neck-Shoulder Pain in Women Industrial Workers: A Randomized Trial Comparing Isometric Shoulder Endurance Training with isometric Shoulder Strength." Archives of Physical and Medical Rehabilitation 81 8 (2000): 1051-1058. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008 <PMID: 10943754>.

Klaber Moffett, J. A., et al. "Randomised Trial of a Brief Physiotherapy Intervention Compared with Usual Physiotherapy for Neck Pain Patients: Outcomes and Patients' Preference." BMJ 330 7482 (2005): 75. National Center for Biotechnology Information. National Library of Medicine. 29 Oct. 2008 <PMID: 15585539>.

General

Sucher, B. M. "Thoracic Outlet Syndrome." eMedicine. Eds. Robert Windsor, et al. 13 Dec. 2006. Medscape. 5 Jan. 2009 <emedicine.com/pmr/topic136.htm>.

Source: Medical Disability Advisor






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