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.

Diabetic Neuropathy


Related Terms

  • Diabetic Nerve Damage

Differential Diagnosis

Specialists

  • Internal Medicine Physician
  • Neurologist
  • Ophthalmologist
  • Orthopedic (Orthopaedic) Surgeon

Comorbid Conditions

Factors Influencing Duration

Factors include the severity of any infection that accompanies underlying diabetes, the degree to which the diabetes is controlled, and amputation of an arm or leg.

Medical Codes

ICD-9-CM:
250.60 - Diabetes with Neurological Manifestations; Type II or Unspecified Type, not Stated as Uncontrolled
250.61 - Diabetes with Neurological Manifestations; Type I [Juvenile Type], not Stated as Uncontrolled
250.62 - Diabetes with Neurological Manifestations; Type II or Unspecified Type, Uncontrolled
250.63 - Diabetes with Neurological Manifestations; Type I [Juvenile Type], Uncontrolled
357.2 - Polyneuropathy in Diabetes

Overview

Diabetic neuropathy is defined as microvascular disease of the nutrient blood vessels of peripheral nerves that brings about neuronal damage (neuropathy) resulting from decreased blood flow (ischaemia) and from metabolic disturbances secondary to elevated blood sugar levels. There are two basic types of neuropathy, peripheral and autonomic, and are differentiated by the nerves affected.

Peripheral neuropathy affects the nerves that branch out from the spinal cord, with distal to proximal death of axons, beginning at the longest nerves. This type of neuropathy tends to develop in stages. It may begin with a tingling sensation that, over time, develops to pain but eventually to a loss of sensation entirely. The most common form is chronic sensorimotor neuropathy which affects the lower extremity in a stocking distribution, with progressive pain, sensory loss, small muscle wasting, and eventually deformity (eg, claw toes).

Autonomic neuropathy involves organs that receive autonomic innervation such as the heart, the digestive system, and the glands. Autonomic neuropathy is characterized by low blood pressure (postural hypotension), diarrhea, constipation, sexual dysfunction, vision problems, eye pain, and other symptoms.

On average, diabetic neuropathy occurs 10 to 20 years after diabetes has been diagnosed, although some diabetics will never develop neuropathy, and others will develop this condition relatively early in the disease process.

Incidence and Prevalence: Ten to sixty-five percent of all patients with diabetes have some sort of disease-related neuropathy, with rates of about 50% occurring in patients who have had the disease for over 25 years.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Patients at risk for diabetic neuropathy generally have problems controlling their blood glucose levels, serum lipid levels, blood pressure, or body weight. Diabetics over the age of 40 are also at risk for diabetic neuropathy.

Source: Medical Disability Advisor



Diagnosis

History: The individual will have a history of diabetes mellitus, usually for more than 10 years. Symptoms will vary depending on the nerves affected, and will develop gradually over a period of years. Common complaints include tingling, pain, decreased sensation or loss of sensation, particularly in the feet and / or hands, often occurring at night. Drooping of the eyelid, mouth, or face may also occur as nerves to the facial muscles are damaged. If autonomic nerves are affected, diarrhea, constipation, loss of bladder control (urinary incontinence), sexual dysfunction, and difficulty swallowing may be reported. Additional symptoms include vision changes, dizziness (particularly with changes in body position), weakness, speech impairment, and involuntary muscle contractions. Pain may also cause difficulty sleeping.

Physical exam: The exam may reveal a decreased skin temperature, a reddish-blue discoloration of the hands, lower legs, and feet with loss of skin color when the arm or leg is elevated (vascular insufficiency). There may be a decrease or absence of ankle reflexes, and the individual may not be able to distinguish sharp from dull or hot from cold when applied to the skin (2-point discrimination). The most subtle finding is the decrease of vibratory sensation or light touch and pain sensation in the toes. The 10 g monofilament test is easy to apply and is useful to identify patients at risk of foot ulceration. The physician may also find a decrease or absence of pulses or a drop in blood pressure with positional changes from lying or sitting to standing (postural hypotension). The individual's nails may be very thick and have ridges with dryness and cracks in the skin.

Tests: A blood glucose test will confirm the presence of diabetes but nerve conduction studies, quantitative sensory testing, and quantitative autonomic testing may be necessary to determine the presence of diabetic neuropathy. Tests for delayed gastric emptying are sometimes useful.

Source: Medical Disability Advisor



Treatment

Diabetic neuropathy is a progressive disease. Several topical and systemic therapies have been tried to alleviate symptoms of peripheral neuropathy, but few have been subjected to controlled trials. Control of the underlying diabetes is vital. Medications may be prescribed (as needed) to control pain (analgesics, antidepressants and / or anticonvulsants), insomnia (sedatives, antidepressants), anxiety (sedatives, antidepressants), infection (antibiotics), and muscle cramps (muscle relaxants).

Source: Medical Disability Advisor



Prognosis

The process of diabetic neuropathy is not well understood. The disease is progressive. If untreated or poorly treated (those who do not adequately control their blood sugar), outcome is generally poor. If caught early and the underlying cause, diabetes mellitus, is treated aggressively, progression may be stopped or slowed, making for a better outcome. In some individuals, control of glucose levels and medication may restore some degree of nerve function; however, substantial reversal of nerve damage is rare.

Source: Medical Disability Advisor



Complications

Complications of diabetic neuropathy may include bladder infections or muscle wasting (diabetic amyotrophy). Neuropathic edema may occur due to increased blood flow in a foot with reduced sympathetic innervation. In addition, individuals with this condition are at increased risk of traumatic injury including burns, infection, or gangrene. Charcot joint disease is a complication resulting in fractures and collapsing bones in the feet, and occurs in individuals with increased blood flow to the joint due to autonomic disturbances secondary to neuropathy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals should avoid extreme temperature variations or moist/wet areas. Extended/prolonged standing could increase complications, so reassignment to a more sedentary position may be required. The use of gloves and appropriate footwear (safety shoes) may be necessary. Individual should also avoid direct skin exposure to chemicals. Individuals who have lost sensation to a particular body part may need to be reassigned depending on their job requirements. For example, a chef who could not feel pain in the hand would be prone to burns.

For more information, refer to "Disease and Injury Causation," pages 292-294, as well as to "Work Ability and Return to Work," page 333.

Risk: Risk would emanate from jobs that can cause other types of neuropathy and therefore contribute to the diabetic neuropathy.

Capacity: An overlap of neuropathies would suggest some limits or need for work restrictions.

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:

  • How long has individual had diabetes?
  • Does individual have peripheral or autonomic neuropathy?
  • Does individual complain of a tingling, pain, decreased sensation or loss of sensation, particularly in the feet or hands?
  • Does individual have postural hypotension, drooping of the eyelid, mouth, or face?
  • Does individual have diarrhea, constipation, urinary incontinence, sexual dysfunction, difficulty swallowing, vision changes, dizziness (particularly with position changes), weakness, speech impairment, and involuntary muscle contractions?
  • Does pain cause difficulty sleeping?
  • On exam does individual have decreased skin temperature, a reddish-blue discoloration of the hands, lower legs, and feet with vascular insufficiency? Is there a decrease or absence of ankle reflexes? Is individual able to distinguish sharp from dull or hot from cold? Is there an absence of pulses? Postural hypotension? Abnormal nails and skin?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Is individual receiving treatment that is aimed at alleviating symptoms?
  • Does individual have control of the underlying diabetes?
  • If needed, have medications been prescribed to control pain, insomnia, anxiety, and / or muscle cramps?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect the ability to recover?
  • Does individual have any complications such as bladder infections, diabetic amyotrophy, and traumatic injury including burns, infection, or gangrene?

Source: Medical Disability Advisor



References

Cited

Lin, Helen C. , and Dianna Quan. "Diabetic Neuropathy." eMedicine. Ed. Nicholas Lorenzo. 9 Jul. 2012. Medscape. 3 Jun. 2013 <http://emedicine.medscape.com/article/1170337-overview>.

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

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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