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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.

Sarcoidosis


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Rehabilitation | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
135 - Sarcoidosis; Besnier-Boeck-Schaumann Disease; Lupoid (Miliary) of Boeck; Lupus pernio (Besnier); Lymphogranulomatosis, Benign (Schaumanns); Sarcoid (Any Site): NOS, Boeck, Darier-Roussy; Uveoparotid Fever

Related Terms

  • Besnier-Boeck Disease
  • Boeck's Sarcoid
  • Lofgren's Syndrome
  • Schaumann's Disease

Overview

Sarcoidosis is a multisystem disease characterized by collections of inflammatory, non-caseating cells called granulomas. These occur primarily in the lungs and intrathoracic lymph nodes, and less frequently in other body organs (Kamangar).

The disease can be fatal—although it usually is temporary and self-limiting. In most individuals it causes no lasting damage, and it requires no treatment among many individuals (some experiencing spontaneous improvement).

The cause of sarcoidosis remains unknown; the most likely cause is an infectious or noninfectious agent that leads to an inflammatory response in an individual with predisposing genetic factors and an over-reactive immune system.

Incidence and Prevalence: In the US, the incidence is about 11 cases per 100,000 in whites, and 34 cases per 100,000 in blacks (Kamangar). There is a higher incidence of disease in individuals of Scandinavian, German, Irish, Japanese, Chinese, African, Indian, and Puerto Rican descent.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Sarcoidosis occurs mainly in individuals between the ages of 25 to 35 years (Kamangar), although onset may occur at any time from childhood through old age. Females are more likely to develop the condition than males (ratio about 2:1).

Source: Medical Disability Advisor



Diagnosis

History: Symptoms vary depending on the organs involved and the extent of involvement. Some individuals have no symptoms. Initial generalized symptoms, when present, may include fatigue, a vague feeling of bodily discomfort (malaise), fever, night sweats, aching muscles, swollen lymph nodes (lymphadenopathy), loss of appetite (anorexia), and weight loss. Lung symptoms typically include a dry, persistent cough, shortness of breath (dyspnea), chest pain, and wheezing. Eye symptoms may include redness, pain, abnormal sensitivity to light (photophobia), or visual disturbances. Löfgren syndrome consists in the triad of painful joints, erythema nodosum, and bilateral hilar lymphadenopathy on chest x-rays, as well as uveitis and fever.

Physical exam: Three physical signs often indicate sarcoidosis: enlarged lymph nodes in the chest, a red raised rash (erythema nodosum), and inflammation in the eye (uveitis). Eye inflammation may cause the presence of inflammatory cells and nodules within the eye. Skin signs may include a rash on the face, arms, shins or ankles; skin sores on the nose, cheeks and ears; color changes; and nodules. There may also be enlargement of the liver (hepatomegaly) and spleen (splenomegaly) and signs specific to involvement of other organs. Involvement of the heart may be evidenced by abnormal rhythm (arrhythmia) or disease of the heart muscle (cardiomyopathy). Involvement of the CNS may be evidenced by paralysis, particularly of the facial muscles (Bell's palsy).

Tests: Chest x-ray may show enlarged lymph nodes and/or infiltrates of the lungs. Biopsy is often not necessary, but may be performed on tissue from the bronchus, skin, lymph nodes, conjunctivae, salivary glands, or liver. Microscopic examination of biopsied tissue typically shows the collections of inflammatory tissue (granulomas).

Blood tests typically show elevated calcium, liver enzymes, and gamma-globulin. Blood angiotensin-converting enzyme (ACE) is elevated in over half of individuals with sarcoidosis.

Pulmonary function tests (PFTs) may be used to detect decreased lung function. If the heart is involved, an electrocardiogram (ECG) may be performed to check heart function.

Source: Medical Disability Advisor



Treatment

The decision to treat depends on the individual's symptoms, the organs involved, and the extent of involvement. Individuals with disease involving the lungs, skin, liver, or joints are treated based on their symptoms. Mild symptoms typically require no treatment. Individuals with more significant symptoms or those with disease involving the eye, heart, or central nervous system do require treatment.

Corticosteroid drugs are the first-line treatment and are prescribed to reduce inflammation, relieve symptoms, and prevent organ damage; treatment is continued for up to 1 year, during which time the drug is gradually tapered or taken only every other day. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for symptomatic relief. If an individual cannot take corticosteroids or does not respond to the drug, a stronger immunosuppressant drug such as methotrexate is given. Drugs that also may be useful are other immunosuppressants such as azathioprine or cyclophosphamide, the alkylating agent chlorambucil, anti-malarial medications such as chloroquine or hydroxychloroquine, the systemic immunomodulator thalidomide, or the tumor necrosis factor-alpha (TNF-alpha) inhibitor infliximab, among others. A topical steroid may be added to the oral corticosteroids to treat eye involvement. Treatment specific to other organ damage is also given. The individual should follow a low-calcium, low-salt diet.

Severe fibrosis of an organ has been treated, rarely, with organ transplant (lung, heart, or liver). Radiation has also been used to treat localized central nervous system involvement.

When treatment is complete, the individual should be checked every 3 months for 1 to 2 years. Chest x-ray and PFT are typically used to monitor disease activity and response to treatment.

Source: Medical Disability Advisor



Prognosis

The predicted outcome for sarcoidosis is variable. Generally, the prognosis is excellent. Many individuals recover fully within 2 to 5 years. Individuals taking corticosteroids typically begin to see improvement within 3 weeks (Kamangar). Approximately 12% of individuals require long-term oxygen therapy, 30% develop pulmonary hypertension, and about 11% eventually die from lung or heart failure (Kamangar). Permanent lung damage is not reversible with drug therapy. Lung transplant with a matched donor lung is the only strategy that may return a healthy lung to an individual with permanent lung damage and failure. Chronic disease may be observed in more than 50% of individuals who require glucocorticoids in the first 6 months after the initial diagnosis; less than 10% of individuals who do not need systemic therapy in the first 6 months will require chronic therapy. About 30% of individuals have stable, chronic disease.

Source: Medical Disability Advisor



Differential Diagnosis

  • Berylliosis
  • Biliary cirrhosis
  • Bronchocentric granulomatosis
  • Brucellosis
  • Chronic inhalation of coal dust or silica
  • Churg-Strauss syndrome
  • Collagen disorders
  • Drug reactions
  • Enlarged pulmonary arteries
  • Hodgkin's disease
  • Idiopathic hemosiderosis
  • Infectious mononucleosis
  • Lymphomatoid granulomatosis
  • Malignancies or metastatic cancer
  • Necrotizing sarcoid granulomatosis
  • Parasitic infection
  • Pulmonary eosinophilia
  • Q fever
  • Tuberculosis
  • Wegener's granulomatosis

Source: Medical Disability Advisor



Specialists

  • Cardiovascular Internist
  • Dermatologist
  • Internal Medicine Physician
  • Neurologist
  • Ophthalmologist
  • Preventive Medicine Specialist
  • Pulmonologist

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation of sarcoidosis needs to be modified depending on the region of the body most affected, especially in cases where the central nervous system is involved.

If the individual has a lung affected by the disease, the disorder is first treated and then followed by pulmonary rehabilitation as needed for the recovery period. Physical therapy with breathing exercises improves ventilation of the individual experiencing sarcoidosis.

Once breathing improves, focus is then placed on strength and endurance by adding gradual strengthening exercises. By building endurance, the individual increases the ability to work and the resistance to fatigue. As endurance increases without shortness of breath, light upper and lower extremity exercises are initiated. Frequency of the program may vary somewhat, depending on the individual's general health.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Complications of sarcoidosis depend upon the organ affected, the extent of disease, and the time to resolution. Lesions in the muscles, heart, lungs, liver, spleen, central nervous system, or eyes may be expected to result in more complications than lesions of the skin or lymph nodes. For example, heart involvement can lead to congestive heart failure and serious arrhythmias. Eye involvement may lead to blindness, although this is rare.

Sarcoidosis and corticosteroid drugs leave a person vulnerable to certain opportunistic infections: tuberculosis, aspergilloma, candidiasis, and cryptococcosis.

Source: Medical Disability Advisor



Factors Influencing Duration

The length of disability is influenced by the size and location of the lesions, the organs or tissues affected, and the response to treatment.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Sarcoidosis is generally not debilitating. The individual's lungs should be protected by avoiding exposure to smoke, dust, and chemicals. Additional work restrictions depend on the location of the lesions and the extent of damage to the affected tissues or organs. If the lungs or heart are affected, appropriate work accommodations may be required until the symptoms subside. Long-term accommodations may be required if the disease relapses, persists for long periods, or causes permanent damage to essential tissues and organs.

Risk: Risk of worsened symptoms may be offset in the work environment by taking appropriate steps to protect the lungs with protective equipment. Work environments following OSHA standards should not put an individual at risk.

Capacity: Capacity may be temporarily decreased in individuals with dyspnea, chest pain, or wheezing. Long-term capacity may be affected by cardiopulmonary involvement, which may be objectively quantified with PFTs and Stress ECHO testing.

Tolerance: Tolerance depends on the extent of the disease and the organ systems involved. Individuals with mild sarcoidosis may be asymptomatic and are not expected to have a reduced tolerance for work. Medication optimization may also help re-assure return to work.

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:

  • Does individual have symptoms suggestive of sarcoidosis, such as fatigue, malaise, fever, night sweats, aching muscles, lymphadenopathy, anorexia, and weight loss?
  • Does individual have lung symptoms, such as a dry, persistent cough, dyspnea, chest pain, and wheezing?
  • Does individual have a rash on the face, arms, shins or ankles; skin sores on the nose, cheeks and ears; color changes; and nodules?
  • Does individual have an ethnic background that puts him/her at increased risk of developing the disease?
  • Did the symptoms arise between the ages of 20 and 40 years of age?
  • Were the findings in the physical exam consistent with the characteristic findings in sarcoidosis (enlarged chest lymph nodes, rash, uveitis)?
  • Were other conditions with similar features ruled out?

Regarding treatment:

  • Based on the severity of symptoms, was the appropriate treatment administered? Were associated organ-specific symptoms addressed in the treatment plan? Were the corticosteroids tapered appropriately?
  • Has individual been monitored every 3 months following completion of treatment?
  • Were other, more aggressive treatments (organ transplant) indicated?

Regarding prognosis:

  • Has sufficient time passed since diagnosis?
  • Did individual suffer any permanent damage from advanced disease?
  • Does individual have any conditions (other lung disorders) that may complicate treatment or impact recovery?
  • Did individual suffer any opportunistic infections (tuberculosis, aspergilloma, candidiasis, and cryptococcosis) associated with the disease or corticosteroid use that affected recovery and prognosis?

Source: Medical Disability Advisor



References

Cited

Kamangar, Nader. "Sarcoidosis." medscape.com. 31 Oct. 2014. 5 Nov. 2014 <http://emedicine.medscape.com/article/301914-overview>.

Source: Medical Disability Advisor