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.

Gout


Related Terms

  • Gouty Arthritis
  • Podagra

Differential Diagnosis

Specialists

  • Internal Medicine Physician
  • Nephrologist
  • Rheumatologist

Comorbid Conditions

Factors Influencing Duration

Length of disability may be influenced by the duration of the disease, the method and effectiveness of treatment, the joint affected, and the individual's job requirements.

Medical Codes

ICD-9-CM:
274.00 - Gouty arthropathy, unspecified
274.01 - Acute gouty arthropathy
274.02 - Chronic gouty arthropathy without mention of tophus (tophi)
274.03 - Chronic gouty arthropathy with tophus (tophi)
274.10 - Gouty Nephropathy, Unspecified
274.81 - Gouty tophi of ear
274.82 - Gouty Tophi of Other Sites; Gouty Tophi of Heart
274.89 - Gout with Other Specified Manifestations, Other
274.9 - Gout, Unspecified
984.9 - Toxic Effects of Lead and Its Compounds (Including Fumes), Unspecified Lead Compound

Overview

Gout is a metabolic disease in which uric acid crystals accumulate in one or more joints, leading to inflammation, swelling (edema), severe pain, and arthritis. Gout tends to involve joints of the lower extremities; the great toe is affected in about 50% of patients (Miller). The foot instep, ankle, heel, wrist, elbow, fingers, and joint at the base of the thumb (carpometacarpal joint) also may be affected. Over time, deposits of uric acid crystals may cause deformity of the joints and severe disability.

In addition to acute inflammatory arthritis, other manifestations of gout may include deposits of sodium biurate (tophi) that cause lumps in soft tissues near the affected joint(s), at the rim of the ear, in the kidney (renal tophi), or in the urinary tract (urinary stones or urolithiasis). Although chronic elevation of uric acid in the blood (hyperuricemia) is necessary for gout to develop, other factors are also important; most individuals with elevated uric acid levels do not develop gout.

Either an overproduction or an under-excretion of uric acid may cause gout. Most attacks occur without an apparent cause, but occasionally an attack may follow an operation, infection, trauma, or dietary/alcoholic overindulgence.

Incidence and Prevalence: More than 1 million Americans are estimated to be affected by gout (“Gout”). The prevalence of gout in men is 1,360 cases per 100,000 individuals; in women, prevalence is 640 cases per 100,000 individuals (Miller).

Source: Medical Disability Advisor



Causation and Known Risk Factors

In susceptible individuals, the risk of a gout attack increase with alcohol consumption, starvation or rapid weight loss, dehydration, hemorrhage, overindulgence in foods with high purine content (e.g., organ meats, oily fish), ingestion of drugs that cause changes in urate concentration (e.g., diuretics), or minor trauma. There is a hereditary predisposition to gout, with 20% of individuals in affected families developing the disease ("Questions and Answers About Gout").

Gout is more common in men than in women. Initial attacks of gout in men most often occur between the ages of 40 and 60 years and in women between the ages of 60 and 80 (Miller). Gout rarely occurs in premenopausal women.

Source: Medical Disability Advisor



Diagnosis

History: The individual may complain of the sudden onset of a red, hot, swollen, and exquisitely tender joint; pain usually is limited to one joint, but occasionally occurs in multiple joints. Often the pain begins at night and is severe enough to wake the individual from sleep. Some individuals may report that the pain disappears after a few hours, while others may have pain that lasts for several weeks. The individual may report that the pain disappears spontaneously and then returns after a period of months.

Physical exam: Because the initial findings with gout typically involve the acute onset of single-joint arthritis, findings on physical exam may include a reddened, warm, swollen, tender joint (Miller). Pain is elicited with slight pressure. If the individual has had high levels of uric acid over many years, he or she also may have tophi in the soft tissues of the ear, hand, foot, or elbow.

Tests: Blood chemistry and a 24-hour urine collection are done to assess uric acid levels; complete blood count (CBC) with differential, and erythrocyte sedimentation rate (ESR), are also done. Diagnosis involves either aspiration of the joint (arthrocentesis) with microscopic examination for urate crystals or tissue biopsy for evaluation of tophi. X-rays of the involved joint may be done to rule out other conditions. A bone scan or magnetic resonance imaging (MRI) may be used to detect all areas involved.

Source: Medical Disability Advisor



Treatment

During an acute attack, the affected joint(s) should be rested. Drugs are the mainstay of treatment. During an attack, these may include non-steroidal anti-inflammatory drugs (NSAIDs), a specific anti-gout agent called colchicine, and sometimes oral corticosteroids when the individual cannot tolerate NSAIDs or colchicine. NSAIDs are given at the highest dose for the first 2 to 3 days, then tapered down over 2 weeks and stopped when symptoms have resolved for at least 2 days (Miller). During an acute attack affecting one joint, corticosteroids may be injected directly into the joint (intra-articular injection).

In chronic gout, drugs that increase the excretion of uric acid in the urine (uricosuric agents) and those that block the production of uric acid (e.g., allopurinol) are used. Individuals are urged to lower the purine content of their diet by limiting consumption of organ meats; alcohol also should be avoided, especially beer and hard liquor, because alcohol both increase the production of uric acid and interfere with the elimination of uric acid. Weight loss is recommended for obese individuals in order to ease strain on affected joints.

Source: Medical Disability Advisor



Prognosis

An acute attack of gout typically will last for 3 to 10 days (“Questions and Answers About Gout”). Treatment should begin as soon as symptoms appear. A second attack occurs in 62% of individuals within 1 year after the initial attack, in 78% of individuals 2 years after initial onset, and in 93% of individuals 10 years after the first attack (Miller). After a second attack, lifelong use of drugs to increase uric acid excretion and block the production of uric acid usually is effective. If left untreated, gout can lead to kidney damage and to severe joint destruction that may require reconstructive surgery of the affected joint(s).

Source: Medical Disability Advisor



Rehabilitation

Generally, rehabilitation recommendations for those with gout are similar to recommendations given to individuals with other forms of arthritis. Individuals who experience complications of joint deformity and immobility may benefit from outpatient physical therapy for range of motion exercises, to control pain and inflammation, and to increase flexibility.

During an acute attack, therapists instruct individuals in the application of heat or ice or both while the joint is rested. Heat reduces stiffness and pain by relaxing muscles, increasing circulation, and helping to dissolve the uric acid crystals. Ice decreases joint pain by numbing the area and blocking nerve impulses. After the attack subsides, therapists instruct the individual in gentle stretching and strengthening exercises for the affected joint(s). The individual learns to perform these exercises independently to help reduce impairment due to joint stiffness and deformity. Individuals who develop gait abnormalities may be trained to walk with a cane to decrease stress through the lower extremities. Orthotics may be helpful when gout affects the foot or toes.

Occupational therapy may be needed to address activities of daily living such as dressing and bathing and to instruct individuals in joint protection and energy conservation. For example, individuals may need to shower while sitting on a tub seat due to lower extremity joint pain and use a long-handled sponge to reduce stress on upper extremity joints. For those individuals who have arthritis in the fingers, wrist, or hand, occupational therapists can order adaptive equipment such as jar-openers, utensils with thicker handles, and elastic shoelaces to decrease stress on joints during daily activities.

Source: Medical Disability Advisor



Complications

Complications include chronic arthritis, bone deformity, death of bone tissue due to insufficient blood supply (avascular necrosis), kidney damage, and high blood pressure (hypertension). Tophi may open and drain and become infected. Severe joint damage may occur. Half of individuals with gout will experience delayed healing after surgery (Rothschild).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Most individuals will require a leave of absence during an acute attack. If the individual continues to work, temporary reassignment to sedentary duties may be required for those whose job responsibilities require prolonged standing or walking or repetitive movements. With chronic gout, individuals may need additional time off for follow-up care every 1 to 2 months until target uric acid levels have been reached, and every 6 to 12 months thereafter (Miller).

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:

  • Were blood chemistry and a 24-hour urine collection to assess uric acid levels done? Erythrocyte sedimentation rate, CBC with differential?
  • Was diagnosis of gout confirmed through arthrocentesis with microscopic examination for urate crystals, or by tissue biopsy for evaluation of tophi?
  • Were x-rays of the involved joint done to rule out other conditions with similar symptoms? Was MRI or bone scan necessary?
  • Does individual have any coexisting conditions that may complicate treatment or affect recovery?

Regarding treatment:

  • Has individual been placed on appropriate medications such as NSAIDs or anti-gout medications?
  • Did individual need oral corticosteroids? Intra-articular injection?
  • Has the individual been instructed to follow a diet low in purines? Is individual limiting alcohol consumption? Would individual benefit from consultation with a nutritionist?
  • If appropriate, has individual been instructed to lose weight? Would individual benefit from enrollment in a weight loss program?
  • Did individual need physical therapy? Occupational therapy?

Regarding prognosis:

  • Did the individual seek treatment when symptoms first occurred?
  • Is the individual compliant with the treatment plan? If not, what can be done to enhance compliance?
  • If attacks recur, is individual on an effective program of uric acid adjustment, which requires lifelong use of medication? Is individual capable of following a long-term medication regimen?
  • Has individual developed complications such as avascular necrosis, bone deformity, kidney damage, or chronic arthritis? Has severe joint damage occurred? If so, are complications being adequately addressed in the treatment plan?

Source: Medical Disability Advisor



References

Cited

"Gout." University of Washington Orthopaedics & Sports Medicine. 22 Dec. 2004. University of Washington. 9 Oct. 2009 <http://www.orthop.washington.edu/uw/tabID__3376/ItemID__34/mid__10313/Articles/Default.aspx >.

"Questions and Answers About Gout." National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dec. 2006. National Institutes of Health (NIH). 9 Oct. 2009 <http://www.niams.nih.gov/Health_Info/Gout/default.asp#stages>.

Miller, Anne V., Sriya M. Ranatunga, and Mark L. Francis. "Gout." eMedicine. Eds. Francisco Talavera, et al. 20 Feb. 2009. Medscape. 9 Oct. 2009 <http://emedicine.medscape.com/article/329958-overview >.

Rothschild, Bruce M. "Gout." eMedicine. Eds. Jegan Krishnan, et al. 27 Feb. 2009. Medscape. 9 Oct. 2009 <http://emedicine.medscape.com/article/1267449-overview>.

General

Smelser, Christopher D., Robert D. Stoffey, and Amilcare Gentili. "Gout." eMedicine. Eds. Guiseppe Guglielmi, et al. 27 Aug. 2009. Medscape. 9 Oct. 2009 <http://emedicine.medscape.com/article/389965-overview>.

Source: Medical Disability Advisor






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