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.

Diabetes with Peripheral Circulatory Disorders


Related Terms

  • Circulatory Disorders
  • Lower Extremity Arterial Disease (LEAD)
  • Peripheral vascular disease

Differential Diagnosis

Specialists

  • Emergency Medicine Physician
  • Endocrinologist
  • Family Physician
  • Interventional Radiologist
  • Ophthalmologist
  • Radiologist
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

Length of disability may be influenced by the severity of peripheral vascular disease, the complications of diabetes that may be present, any comorbidities present, the extent of vascular/circulatory obstruction, the type of treatment required, the timeliness of treatment, and the development of complications associated with treatment.

A longer hospital stay is usually associated with surgical intervention than with angioplasty.

Medical Codes

ICD-9-CM:
250.70 - Diabetes with Peripheral Circulatory Disorders; Type II or Unspecified Type, Not Stated as Uncontrolled
250.71 - Diabetes with Peripheral Circulatory Disorders; Type I [Juvenile Type], Not Stated as Uncontrolled
250.72 - Diabetes with Peripheral Circulatory Disorders; Type II or Unspecified Type, Uncontrolled
250.73 - Diabetes with Peripheral Circulatory Disorders; Type I [Juvenile Type], Uncontrolled

Overview

Diabetes mellitus (diabetes) is a chronic metabolic disorder characterized by abnormally high levels of glucose in the blood (hyperglycemia). It results when the body fails to produce enough of the hormone insulin that normally regulates glucose and / or when peripheral tissues show resistance to insulin action (type 2 diabetes), or when the body fails to produce insulin at all (type 1 diabetes). Diabetics require lifestyle measures (diet, exercise) and, if these are not enough to achieve a normal blood glucose level (normoglycemia), drugs to lower glucose levels (oral hypoglycemic drugs) and / or daily doses of insulin to prevent serious multisystem complications that can lead to premature death. A range of complications, including circulatory disorders, may develop after years of living with diabetes.

Peripheral circulatory disorders are frequent complications of diabetes. Peripheral vascular disease (PVD) is a condition in which the buildup of plaque (atherosclerosis) obstructs arteries in the extremities, most often in the lower extremities. The vascular disease is characterized by decreased blood circulation to the legs and feet, causing symptoms such as pain in the legs and feet during walking that is relieved with rest (intermittent claudication). Acute symptoms may include those of obstruction of blood vessels by detached pieces of atherosclerotic plaque (emboli) or by blood clots (thrombi), resulting in lack of blood flow to a limb and insufficient perfusion of tissue in the affected area (ischemia).

Other common complications of diabetes, such as decreased sensation in the extremities (peripheral neuropathy) and increased susceptibility to infection, exacerbate peripheral vascular disease by increasing the risk of foot infections and ulcerations, sometimes leading to ischemia, gangrene, and possible amputation of part of the affected extremity. In fact, diabetes is the leading cause of amputations (more than 60%) in the US not caused by trauma to a limb; in 2006, around 65,700 nontraumatic lower-limb amputations were performed in diabetic patients (National Diabetes Statistics, 2011).

Incidence and Prevalence: Population-based studies show that the prevalence of peripheral vascular disease is higher in diabetics than in nondiabetic individuals. The incidence of peripheral vascular disease in individuals with diabetes increases with age and with the duration of the diabetes. One in three diabetics over the age of 50, especially those with a long history of poorly controlled diabetes, have peripheral circulatory disorders.

The international incidence is not known because the exact incidence of diabetes is not known. The incidence of diabetes in developed countries parallels that of the US, and 50% of those with diabetes may be subject to peripheral circulatory disorders, also parallel to rates in the US.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Diabetes is a significant risk factor for peripheral vascular disease (Stephens). Peripheral circulatory disorders tend to occur in those who have long-standing, poorly controlled diabetes (greater than 10 years), and risk increases with age, as it does in nondiabetic individuals (Stephens). These disorders are found in less than 20% of those who have been diagnosed with diabetes for less than 2 years, but they occur in almost 40% of those who have had diabetes for 20 years. The risk of developing atherosclerosis and subsequent peripheral vascular disease in diabetics increases in those who also have hypertension and hyperlipidemia. Diabetics who smoke also increase their risk of developing circulatory disorders. The risk is also high among diabetics who do not maintain control of their diabetes by following a physician-recommended regimen and who may be more subject to developing complications. However, complications do occur in some individuals, even with effective control of the disease.

Source: Medical Disability Advisor



Diagnosis

History: Often individuals complain of cramping pain in the calf, thigh, groin, or buttocks. They may report that the pain is precipitated by walking and disappears during rest (intermittent claudication). This pain may be limited to one side, or be present in both lower extremities. Individuals may report a change in the color of their feet and / or legs. For many, the presence of blisters, of wounds that are slow to heal, or of black discoloration on their feet or higher parts of the lower extremities prompts them to seek medical attention.

Physical exam: The physical exam may reveal decreased or absent pulses in the feet, the ankles, and sometimes the lower leg. This alone may be diagnostic, particularly if other symptoms are absent. The affected limb or limbs may show decreased muscle size (atrophy); absence of hair; smooth shiny skin; diminished nail growth; and thickened, brittle toenails. If the circulation is severely reduced, the skin may be cool to the touch, and the limb may be reddish, pale, or bluish (cyanosis). Swelling (edema), as well as cracked skin, blisters, or skin ulcers, may be present. Skin ulcers that have associated tissue death (gangrene) may appear black and crusty. Rarely, the skin may have a crackling sound and feel when touched, which is indicative of gas gangrene.

Tests: Routine blood tests for evaluating suspected obstruction of blood flow to an extremity include complete blood count (CBC), blood urea nitrogen (BUN), creatinine, and electrolytes. A lipid profile and coagulation tests are also necessary to determine the extent of atherosclerosis and potential for blood clot formation. An ankle brachial index (ABI), which compares the ratio of the systolic blood pressure at the ankle to the systolic blood pressure of the brachial artery (arm), is often used to determine the presence of peripheral circulatory disorders. It may be of limited value in diabetics, however, who tend to have firm, calcified vessels that can distort the blood pressure measurement. Doppler ultrasound imaging uses reflected sound waves to show the flow of blood through veins and arteries and is especially effective in revealing blood clots. It involves placing an ultrasound probe (transducer) on pulse points on the legs and feet where high-frequency sound waves bounce off soft tissue and Doppler echoes are recorded. Doppler echoes are converted to images on a monitor, while pulse sounds are recorded to help show the speed and direction of blood flow through arteries. Recordings of diminished flow indicate peripheral vascular compromise. Conventional angiography can directly measure the degree of vascular occlusion and its location. MRI of the arteries, called magnetic resonance angiography (MRA), may be used as a noninvasive means to visualize the vascular occlusion.

Source: Medical Disability Advisor



Treatment

The objective of treatment of peripheral vascular disorders in diabetics is to limit the progression of the vascular obstruction by atherosclerotic plaque or blood clots. Mild peripheral vascular disorders may be treated medically, using a combination of diet, exercise, and medications to maintain normal blood sugar levels and to enhance circulation. Medications may include antidiabetic agents, insulin, vasodilators to increase the opening (lumen) within blood vessels, and platelet inhibitors to discourage the formation of clots.

More advanced disease often requires invasive treatment, such as interventional radiology procedures or surgery. Intra-arterial thrombolytic agents may be needed to dissolve blood clots in some individuals. Balloon angioplasty is a minimally invasive interventional radiology procedure that is being done to restore circulation in uncomplicated peripheral vascular disorders. In this procedure, a balloon catheter is introduced through a large leg vessel and directed to the site of vascular occlusion. The balloon of the catheter is inflated to open the blood vessel and reestablish blood flow. To remove emboli, a balloon catheter may be passed next to or above the lesion and inflated; the emboli is then withdrawn with the catheter. In some cases, a hollow, slightly rigid, cage-like device called a stent is placed in the vessel to act as scaffold to hold the vessel open and maintain circulation. Bypass surgery is the definitive treatment when significant PVD is present. This revascularization procedure involves surgically implanting a graft to bypass the affected vessel (i.e., femoral artery or popliteal artery) to restore adequate circulation. It carries a 5-year patency rate of about 90%, but significant PVD in diabetics is often accompanied by comorbidities such as cardiovascular disease and chronic obstructive lung disease, which may increase morbidity and mortality (Stephens).

Source: Medical Disability Advisor



Prognosis

The prognosis is dependent on the extent of vascular disease, the type of treatment required, the individual's response to treatment, and the existence of comorbid conditions. Peripheral vascular disease in diabetics may result in obstruction of blood flow (ischemia), infections, and death of limb tissue (gangrene), leading to amputation of part or all of an affected limb and sometimes death. In those treated with surgical revascularization, the rate of maintaining open blood vessels (patency rate—about 90%) is slightly better than in those who receive angioplasty intervention (Stephens). However, surgical intervention requires a longer hospital stay and, because of comorbid illnesses common in diabetics, is associated with greater morbidity and mortality.

Source: Medical Disability Advisor



Complications

Peripheral circulatory disorders in diabetic individuals sometimes lead to ischemia, gangrene, and possible amputation of part of the affected extremity.

Complications associated with balloon angioplasty are infrequent and include thrombosis, vessel dissection, hematoma formation, and formation of a false aneurysm. Some of these complications may require surgical intervention.

Complications associated with surgical revascularization may include reaction to anesthesia, respiratory failure, hemorrhage, infection, circulatory shock, and (rarely) death.

The presence of complications of diabetes or comorbidities often associated with diabetes increases the risk of comorbidities and mortality associated with interventional treatment.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Prolonged sick leave may be required for inpatient therapy and / or surgical treatment and recovery.
For more information on risk, capacity, and tolerance refer to "Work Ability and Return to Work," pages 280-281.

Risk: Risk of working with this condition is probably reflected by the underlying diabetes and not the circulation trouble itself, especially early on in the condition. For more information, refer to "Disease and Injury Causation," page 245.

Capacity: Stress testing to verify walking limit is the best controlled method to verify ability.

Tolerance: Patients may report a hesitation to work with symptoms, but this may be addressed through objective stress tests results.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of severe secondary complications (such as MI, stroke, renal failure), MMI can be determined within 84 days, depending on the complexity of the treatment regimen required.

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:

  • Did the physical exam reveal diminished or absent pulses in the lower extremities?
  • Was routine blood work done, including CBC, BUN, electrolytes, lipid profile, and coagulation tests?
  • Was an ankle brachial index (ABI) done?
  • Was angiography done to confirm diagnosis?
  • Did the physical exam reveal skin abnormalities (redness, pallor, cyanosis) suggestive of advanced peripheral vascular disease?
  • Were ulcers, blisters, or necrotic tissue present on the feet or higher parts of the lower extremities?
  • Has the individual had Doppler ultrasound, x-rays, CT scan, or MRI?

Regarding treatment:

  • Were lifestyle changes and medical management implemented to control diabetes?
  • Was the medical intervention successful in maintaining a normal blood glucose level (normoglycemia)?
  • Have complications of diabetes developed despite treatment?
  • Was balloon angioplasty with or without stenting done?
  • Was surgical revascularization required?
  • Did radiologic or surgical intervention restore blood flow in the affected extremity?

Regarding prognosis:

  • Has patency been maintained after treatment to restore blood flow?
  • Has infection, ischemia, or gangrene developed in the affected limb?
  • If amputation was necessary, is the individual active in a rehabilitation program?
  • Has blood glucose been controlled during hospitalization?
  • Is the individual's employer able to accommodate any necessary restrictions?
  • Does the individual have any comorbid conditions that may affect ability to recover?
  • Has the individual had any complications associated with the condition or treatment?

Source: Medical Disability Advisor



References

Cited

"National Diabetes Statistics, 2011." National Diabetes Information Clearinghouse (NDIC). 2011. National Institutes of Health (NIH). 3 Oct. 2013 <http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm>.

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

Stephens, Everett. "Peripheral Vascular Disease." eMedicine. Eds. David A. Peak, et al. 5 Jan. 2009. Medscape. 15 Aug. 2009 <http://emedicine.medscape.com/article/761556-overview>.

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

Source: Medical Disability Advisor






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