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.

Chest Pain


Related Terms

  • Angina
  • Aortic Dissection
  • Gastroesophageal
  • Myocardial Infarction
  • Noncardiac Chest Pain
  • Nonspecific Chest Pain
  • Pneumonia
  • Pneumothorax
  • Pulmonary Embolism
  • Reflux Disease (GERD)

Differential Diagnosis

  • Angina pectoris
  • Anxiety or panic attack
  • Aortic dissection
  • Aortic stenosis
  • Asthma
  • Bone or soft tissue inflammation
  • Cancer
  • Coronary artery disease
  • Gallbladder inflammation (cholecystitis)
  • Gallstones
  • Gastroesophageal reflux disease (GERD)
  • Hiatal hernia
  • Muscle strain
  • Myocardial infarction (MI)
  • Pancreatitis
  • Peptic ulcer
  • Perforated viscus
  • Pericarditis
  • Pleurisy
  • Pneumonia
  • Pneumothorax
  • Prinzmetal's angina
  • Pulmonary embolus
  • Variant angina

Specialists

  • Cardiovascular Internist
  • Critical Care Internist
  • Emergency Medicine Physician

Comorbid Conditions

Factors Influencing Duration

Length of disability is directly dependent upon diagnosis. For nonspecific chest pain, disability is influenced by the severity, frequency, and duration of pain episodes; the individual's understanding or interpretation of the symptoms; and the presence or absence of a psychiatric disorder. Disability may result not only from pain but also from self-imposed restrictions on activities.

Medical Codes

ICD-9-CM:
786.50 - Chest Pain, Unspecified
786.59 - Chest Pain; Other; Discomfort in Chest; Pressure in Chest; Tightness in Chest

Overview

Chest pain is the sensation of "pressure," "stabbing," or "tightness" that can accompany disorders in the chest wall, chest cavity, back, or abdominal cavity.

Chest pain can be a symptom of many different disorders, ranging in significance from minor to life threatening. Since the nerve supply and pain sensation of the chest is integrated with many structures and organs in or near the chest cavity, any disorder in this broad region can cause chest pain. The pain can arise from the various structures found in the chest such as the heart, aorta, lungs, trachea, bronchi, esophagus, linings of the chest cavity (pleura or pericardium). Pain also can arise from the chest wall, including ribs, breastbone (sternum), muscles, nerves, or breasts. For example, intercostal neuritis, an inflammatory condition affecting the nerves around the ribs, causes chest pain. In addition, pain may be projected (referred) to the chest from other locations in the body, such as the abdomen, spine, or shoulders. Finally, psychological factors may play a role in any chronic or recurrent chest pain. Nonspecific chest pain can be associated with psychiatric disorders, including depression and anxiety disorders, or symptoms for which no physical cause can be found (somatoform disorders).

A common cause of heart-related chest pain is angina pectoris, caused by the heart muscle cells receiving insufficient oxygenated blood (ischemia). Angina pain usually is associated with exertion or emotional stress that places an added workload on the heart muscle. Stable angina pectoris may be present for years. An inadequate blood supply to the heart that is severe or prolonged enough to cause damage to the heart muscle cells, such as in a heart attack (myocardial infarction), produces pain in the same areas as angina, but the pain lasts longer and is more severe. Angina pectoris and myocardial infarction are caused most often by narrowing of the coronary arteries (coronary artery disease [CAD]) or blockage caused by rupture of vulnerable deposits (plaques) in the coronary vessels. This rupture causes bleeding of the blood vessel wall that can lead to blood clot formation and vessel obstruction. Angina also can be caused by temporary coronary spasms (Prinzmetal's angina or variant angina), narrowing of the aortic valve (aortic stenosis), thickening of the heart wall (hypertrophic cardiomyopathy), and acute emotional-stress induced weakening of the heart muscle (takotsubo cardiomyopathy). Angina commonly presents as chest pain radiating to the left neck or arm. In some cases, neck or arm pain may be the only symptom.

Pericarditis, an inflammation of the membrane (pericardium) surrounding the heart, causes sharp pain in the center of the chest. In some cases, it is severe enough to mimic a heart attack. Mitral valve prolapse refers to a common, slight deformity of a valve situated in the left side of the heart. Although usually without symptoms, it occasionally produces chest pain. Disorders of the main artery of the body (aorta) that may cause chest pain include aortic aneurysm (a weakening or ballooning of the wall of the aorta) and aortic dissection (separation of layers due to a tear in the inner layer of the aortic wall).

Chest pain may be caused by pleurisy, which is an inflammation of the membranes (pleurae) that surround the lungs and cover the inner surface of the chest wall. Pleurisy can be caused by many disorders, including viral and bacterial infections (e.g., pneumonia, bronchitis), a collapsed lung (pneumothorax), an injury such as a fractured rib, or any lung disease that extends to the pleura. Cancer of the lung may cause pain as it spreads to the pleura and ribs.

Pulmonary embolism occurs when a blood clot from the venous system becomes lodged in the lungs. A massive pulmonary embolism may produce chest pain similar to that of a heart attack. Clinical findings are elevated central venous pressure and therefore a prominent jugular vein (vena jugularis). Other respiratory diseases that may cause chest pain include acute bacterial pneumonia, a lung abscess, or inflammation of the trachea and bronchi (tracheobronchitis).

Pain in the chest wall may be due to an inflammation of the muscles between the ribs and diaphragm (pleurodynia). It can be caused by a variety of disorders, including viral infection, fibromyalgia, or an inflammation of the joints between the ribs and the breastbone (costochondritis). When warmth, redness, or swelling accompany this inflammation, it is known as Tietze's syndrome. Pain character changes with movements.

Intercostal neuritis is an inflammation of the nerves that run alongside the ribs. Causes of intercostal neuritis include diabetes mellitus and shingles (Herpes zoster).

Other causes of chest wall pain include injuries such as rib or sternum fracture, soft tissue injuries (e.g., strained muscles) intercostal muscle spasm, chest wall tumors, breast disease, or asthma. Chest pain caused by panic or anxiety is often accompanied by rapid breathing and/or dyspnea, heart palpations, sweating, and reported insomnia.

Pressure on nerve roots attached to the spinal cord may result in a sharp pain that travels to the front of the chest. Osteoarthritis, injury to vertebrae, a displaced or prolapsed disc, or other musculoskeletal disorders may cause pain.

Abdominal disorders that can refer pain to the chest include inflammation of the gallbladder (cholecystitis), inflammation of the pancreas (pancreatitis), and peptic ulcers. Occasionally, the referred pain is severe enough to mimic angina pectoris.

The esophagus is a common source of chest pain. Pain may be the result of structural disorders (e.g., esophageal strictures, cancer), inflammation of the esophagus (esophagitis), or functional abnormalities (esophageal spasms). Heartburn (gastroesophageal reflux [GERD]) results from stomach acid being regurgitated into the lower end of the esophagus. This produces pain behind the breastbone. Pain originating from the esophagus can easily be confused with angina pectoris because it mimics it in location, radiation, and quality and can occur with exertion.

Chest pain without a specific diagnosis is referred to as nonspecific chest pain. Chest pain not originating with the heart is referred to as noncardiac chest pain.

Incidence and Prevalence: Because the symptom of chest pain can arise from a variety of disorders, the exact prevalence of chest pain cannot be ascertained. Among the most common causes, heart disease accounts for nearly 900,000 deaths in the US annually; approximately 600,000 individuals develop pulmonary embolism each year, and of these 60,000 die (Cunha). GERD, often accompanied by chest pain, affects approximately one-quarter of people in the US (Cunha). Noncardiac chest pain is twice as common in women as men (“Non-Cardiac Chest Pain”).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Although many disorders can contribute to chest pain, risk of myocardial infarction, the most life-threatening disorder for which chest pain is a common symptom, is greatest among individuals who have a family history of heart disease; smoke; are obese; use cocaine; have high blood pressure (hypertension), high cholesterol (hypercholesterolemia), or diabetes.

Source: Medical Disability Advisor



Diagnosis

History: : Individuals may describe their chest discomfort with terms like sharp, dull, aching, boring, stabbing, crushing, squeezing, pressure, tearing, and burning. They may complain of pain that is localized in the middle of the chest or that radiates to their jaw, back, shoulders, arms, or abdomen. Individuals may report that the pain is sudden or ongoing and may describe things that precipitate the pain or relieve it. They may complain of other associated symptoms, such as sweating, nausea, vomiting, heart palpitations, dizziness, fainting (syncope), shortness of breath (dyspnea), cough, and difficulty swallowing (dysphagia). They may mention a past medical history of heart disease, lung disease, or chest injury. Doctors may question otherwise healthy young individuals experiencing chest pain, who have no obvious risk of heart disease, about recent use of cocaine (McCord). Individuals who complain of sharp chest pain and dyspnea after a long period of inactivity, such as a long sedentary trip or bed rest after surgery, are at risk for having developed blood clots in the legs (deep vein thrombosis) that have broken loose and circulated to the lungs. Associated signs and symptoms of deep vein thrombosis may include swelling (edema) or pain in the legs.

Physical exam: Because chest pain can arise from a variety of different causes, making a definite diagnosis requires a thorough examination. The characteristics of the pain may provide a helpful clue. The exam may reveal pain that increases in intensity when a deep breath is taken, which suggests that the lungs or chest wall are involved. Individuals may present with pain that arises with physical activity, which may be associated with heart conditions. An irregular pulse, change in blood pressure, or abnormal heart sounds may be present, which may indicate heart or lung conditions. Individuals who present with a rapid respiratory rate and abnormal lung sounds may have lung problems such as pneumonia, pleuritis, or pulmonary embolism. Areas that are tender on palpation or with motion of the rib cage, torso, or extremities may represent bruising, muscle tears, or fractures that could be the underlying cause of the pain. Masses (either cancerous or noncancerous) in the chest, back, or abdomen may put pressure on nerves in the chest cavity and result in chest pain.

Tests: A wide variety of diagnostic tests and procedures may be employed in the evaluation of chest pain. Electrocardiography (ECG) to detect deficit blood supply (myocardial ischemia) and other cardiac abnormalities; an ultrasound exam (echocardiogram) to visualize the valves and internal structure of the heart; and a cardiac stress test (exercise tolerance test, treadmill test) are noninvasive measures to exclude chest pain of cardiac origin. A complete blood count (CBC) may be done, along with tests to measure total cholesterol, blood sugar, and relevant protein levels. Cardiac enzyme biomarkers may be measured to diagnose myocardial infarction and determine the extent of any heart muscle damage. Myocardial perfusion scans use a radioactive contrast agent that when injected intravenously passes through the coronary circulation and is taken up by the heart muscle (myocardium). The agent is detected by scintillation cameras, which produce an image of the heart that reveals areas of insufficient blood supply or other abnormalities.

Coronary arteriography (contrast x-ray of the coronary arteries, also called coronary angiography) can be used to confirm or rule out coronary artery disease (CAD). Because this procedure has significant risks, it is usually performed if results of the stress tests are inconclusive or to differentiate coronary spasm from blockage of the coronary arteries. Plain chest x-ray can reveal the abnormal aortic contours characteristic of aortic dissection. A CT scan or angiography can identify dissection more accurately, as can transesophageal echocardiography (TEE) and MRI.

Once cardiovascular disease has been ruled out with reasonable certainty, other causes should systematically be excluded. Endoscopy or an upper GI series (x-rays of the upper gastrointestinal tract) can be used to rule out peptic ulcer disease or structural abnormalities of the esophagus. Abdominal ultrasound exam can screen for diseases of the gallbladder, pancreas, and liver. Gastroesophageal reflux disease can be checked by measuring esophageal pH. Esophageal spasm and other motility disorders can be diagnosed by measuring the pressure of gases and vapors in the esophagus (esophageal manometry).

Pain can result from an interaction of physical disorders and psychological factors (e.g., anxiety, panic attack). If emotional or behavioral symptoms are prominent and no specific cause of chest pain can be identified, a psychological or psychiatric evaluation may be indicated.

Source: Medical Disability Advisor



Treatment

The treatment of chest pain depends on the specific diagnosis and is directed at correcting the underlying cause to prevent the reoccurrence of pain and associated problems. In many cases, however, no specific diagnosis can be determined.

Once serious disease has been ruled out, treatment of chest pain of undetermined origin (nonspecific chest pain) begins with reassurance that the pain is not a symptom of serious disease. The physician should recognize, however, that some individuals with nonspecific pain may go on to develop coronary artery disease (CAD), so teaching lifestyle modification techniques (e.g., changes in diet, exercise) to reduce risk factors may be indicated. In particular, women diagnosed with nonspecific chest pain may be at increased risk for subsequent coronary artery disease events, including angina and nonfatal myocardial infarction (Robinson).

For pain relief, medical treatment is based on what works (efficacy). For pain of suspected musculoskeletal origin, treatment begins with rest, local application of heat or cold, and pain relievers. Anti-anginal drugs may relieve symptoms in some individuals, even if there is no evidence of CAD or coronary spasm. When anti-anginal drugs are prescribed, it should be made clear to the individual that they are not being prescribed for any detectable heart disease.

Gastrointestinal disorders such as GERD can be treated with diet, lifestyle changes, and medications, including antacids, proton pump inhibitors, and H-2 blockers, Esophageal spasms may be treated with anti-cholinergic drugs or calcium channel blockers, which can provide relaxing effects on esophageal muscles. Tricyclic antidepressants are thought to have a pain-relieving effect independent of their antidepressant action and may be used in low dose for chronic chest pain presumed to be of musculoskeletal origin. If depression is a contributing factor, that would be a further indication for these drugs, although other classes of antidepressants have fewer side effects and tend to be the preferred for treatment of depression. If anxiety is prominent, anti-anxiety drugs may be given. Relaxation techniques such as biofeedback also may be helpful. Psychotherapy or behavioral therapy may be considered, particularly in individuals who have been diagnosed with a psychiatric disorder. Individuals without psychiatric disorders may also benefit from short-term psychological or behavioral therapy to help them understand and cope with their symptoms.

Source: Medical Disability Advisor



Prognosis

The prognosis of chest pain depends on the specific diagnosis. Individuals with nonspecific chest pain have a low incidence of heart problems. From that standpoint, the prognosis is excellent. However, most of these individuals continue to have recurrent pain. Nonspecific chest pain is statistically associated with an increased incidence of psychiatric disorders, including depression, anxiety disorders, and somatoform disorders. Many individuals continue to worry about heart disease, despite reassurance. Whether pain leads to psychological disturbance, or vice versa, is not always clear. Despite the absence of disease, the prognosis for return to work is often poor, particularly if a psychiatric disorder is present.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation used for chest pain depends on the cause and origin of the symptoms. If the cause is from muscle spasm involving one or more of the chest muscles, a decrease in the present activity followed by stretching usually reduces the symptoms. The physical therapist often instructs individuals in various stretching techniques that do not involve machines or hands-on methods.

If the chest pain comes from the heart muscle (angina), the goal is to design a physical conditioning program for the individual that increases the amount of activity, yet limits the onset of symptoms from this form of chest pain. In these cases, individuals must first identify and communicate that their symptoms are true angina pain. The physical therapist or other healthcare personnel knowledgeable in treating various forms of angina uses a scale to rank angina symptoms that help determine the amount and intensity of the prescribed exercise.

Treatment of chest pain is monitored by the rehabilitation professional throughout low-demand aerobic activities. If treatment occurs in a hospital setting, individuals are monitored for heart rate, rhythm, blood pressure, and chest pain. Incorporating work-type activities into the rehabilitation regimen will address endurance that may be needed upon return to work. This increase in endurance will also translate into a generally more active lifestyle.

Because of the various degrees and effects each individual experiences with chest pain and other forms of angina, modifications may be needed for those individuals taking various medications or who experience other conditions that result in chest pain.

Source: Medical Disability Advisor



Complications

Complications depend on the underlying condition. Individuals with nonspecific chest pain may continue to have recurrent pain. Many continue to worry about heart disease despite reassurance, which may lead to self-imposed activity restrictions and frequent emergency room visits.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

For nonspecific chest pain, heavy or strenuous activity may need to be restricted if it produces or aggravates symptoms. Individuals with diagnosed angina or asthma should follow physician instructions and take medication as directed to avoid or reduce recurrence. Company policy on medication usage should be reviewed to determine if prescribed medication use is compatible with job safety and function.

Individuals at risk for myocardial infarction benefit from educational activities, along with diet and exercise regimens that can help them to achieve and maintain a normal weight, control hypertension, hypercholesterolemia, and diabetes, quit smoking or avoid second-hand smoke, and reduce workplace or personal stress. Individuals whose chest pain originates with esophageal spasm or GERD may also benefit from smoking cessation programs, as well as stress reduction techniques and activities.

To discourage development of the deep vein thrombosis that can lead to pulmonary embolism, employees who travel on extended airplane or automobile trips should find opportunities for walking, stretching, or otherwise moving the legs. Isometric contractions of the calf muscles are helpful in situations where travelers must remain seated.

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 angina pectoris?
  • Does individual have underlying lung, heart, esophageal, stomach, or inflammatory conditions?
  • Did the individual recently emerge from a period of inactivity, such as bed rest or sedentary travel?
  • Has individual had a recent bacterial or viral infection?
  • Is chest pain chronic or recurrent, suggesting involvement of psychological factors?
  • Has individual had a recent injury to the chest wall, such as fractured ribs or sternum, or a soft tissue injury such as strained muscles?
  • How does individual describe the pain? Is it sharp, dull, aching, boring, stabbing, crushing, squeezing, pressured, tearing, or burning?
  • Where in the chest is the pain localized? Under the breastbone? Only on one side?
  • Is the pain limited to the chest, or does it radiate to the jaw, back, shoulders, arms, or abdomen?
  • Does anything in particular, such as medication or activity, precipitate the pain or relieves it?
  • Is the pain accompanied by other symptoms, such as sweating, nausea, vomiting, heart palpitations, dizziness, syncope, dyspnea, cough, or difficulty swallowing?
  • Were electrocardiogram (ECG), echocardiogram, or stress test (exercise tolerance test) done?
  • Were invasive tests, such as myocardial perfusion scan or coronary arteriography, required?
  • Was chest pain caused by a cardiac abnormality?
  • If not, were other tests, such as an upper gastrointestinal tract x-rays, abdominal ultrasound, or esophageal manometry done to rule out other conditions?
  • Was a specific diagnosis confirmed, or does individual have nonspecific chest pain?

Regarding treatment:

  • What is the underlying cause of the chest pain?
  • If individual is at risk for development of coronary artery disease, have lifestyle modification techniques, such as diet and exercise been instituted? Is individual compliant?
  • What kind of medication was administered? Has the pain effectively been relieved?
  • If anti-anginal drugs were given, does individual with nonspecific chest pain understand they were not prescribed for any detectable heart disease?
  • Were gastrointestinal drugs prescribed, such as antacids, proton pump inhibitors, H-2 blockers, anti-cholinergic drugs, or calcium channel blockers?
  • Did these medications provide relief from pain?
  • Do psychological causes of pain need to be explored? If so, has individual had a psychiatric evaluation and/or participated in psychotherapy or behavioral therapy?
  • Does individual require medication for any diagnosed psychiatric disorder?
  • Has individual been instructed in biofeedback or other relaxation techniques?

Regarding prognosis:

  • Was a specific diagnosis able to be determined?
  • If so, what was the diagnosis and how was it treated? Are other treatments available?
  • If pain is psychological in origin, is individual seeing a psychiatrist or psychologist?
  • If pain results from an underlying condition, have additional complications developed?
  • If so, what are the complications and what is the expected outcome with treatment?
  • Can individual’s employer accommodate any necessary limitations on strenuous activity?
  • Are workplace educational or recreational resources available to help individuals at risk for myocardial infarction develop more healthful lifestyle habits and better address any comorbid conditions?
  • Are workplace educational or recreational resources available to help individuals with GERD or esophageal spasm develop more healthful lifestyle habits and better address workplace or personal stress?

Source: Medical Disability Advisor



References

Cited

"Non-cardiac Chest Pain." Cleveland Clinic Foundation. 3 2005. 6 Mar. 2009 <http://my.clevelandclinic.org/disorders/gastroesophageal_reflux_gerd/hic_non-cardiac_chest_pain.aspx>.

Cunha, John P. "Chest Pain." eMedicine. Eds. Melissa Conrad Stoppler, et al. 1 May. 2008. Medscape. 6 Mar. 2009 <http://www.emedicinehealth.com/chest_pain/article_em.htm>.

McCord, James. "Management of Cocaine-associated Chest Pain and Myocardial Infarction." Circulation 117 (2008): 1897-1907.

Robinson, J. G. "Cardiovascular Risk in Women with Non-specific Chest Pain (from the Women's Health Initiative Hormone Trials)." American Journal of Cardiology 102 (1008): 693-699.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.