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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.

Grand Mal Seizure


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 | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
345.00 - Generalized Nonconvulsive Epilepsy without Mention of Intractable Epilepsy
345.10 - Generalized Convulsive Epilepsy without Mention of Intractable Epilepsy
345.11 - Generalized Convulsive Epilepsy with Intractable Epilepsy
345.3 - Grand Mal Status

Related Terms

  • Convulsion
  • Epilepsy
  • Generalized Convulsive Epilepsy
  • Major Epilepsy
  • Tonic-clonic Convulsion
  • Tonic-clonic Seizure

Overview

Grand mal seizures, also called tonic-clonic seizures, are caused by abnormal electrical activity in the brain. Normal human activities, thoughts, perceptions, and emotions are produced by electrical impulses that stimulate nerve cells in the brain. During a seizure, the usual electrical communication in the brain is disrupted by a chaotic and unregulated discharge. Seizures are a symptom of brain dysfunction and can be the result of a wide variety of diseases or injuries. Seizures are usually due to unknown factors affecting brain electrical activity but may be associated with birth trauma, head injury, central nervous system infections, brain tumor, stroke, ingestion of toxic substances, or metabolic imbalance.

A grand mal seizure starts with the mouth and eyes opening. The arms are thrown out and up, and the legs straighten. The respiratory muscles contract, forcing air out of the lungs and creating a sound like a cry or a grunt. The jaws clamp shut, and the individual may bite his or her tongue. Breathing ceases, and the bladder can contract, releasing urine (incontinence). The body collapses and is rigid. The individual loses consciousness. This is called the tonic phase of the seizure and lasts for about 15 to 30 seconds.

The clonic phase immediately follows and is characterized by violent rhythmic muscular contractions of the entire body, including the muscles of the face and eyes. The individual does not breathe normally because the respiratory muscles are also involved (apnea). The movements gradually subside, and the seizure is over in 1 to 2 minutes. Breathing becomes regular, and the individual falls asleep. Individuals may waken within a few minutes or sleep may persist for up to several hours in some cases. On awakening the individual will be confused, lethargic, and fatigued. This mental state may persist for hours. The individual often has a headache and fails to remember the seizure or events preceding it. This is called the post-ictal phase.

Seizures with no apparent cause are called idiopathic seizures. Most grand mal seizures in adults are idiopathic seizures, although there appears to be a genetic component to these seizures. Grand mal seizures may also be due to microscopic brain lesions that occurred at birth or from trauma, or unexplained metabolic disturbances. Grand mal seizures may accompany meningitis, herpes simplex virus infections, cerebral tuberculomas, brain tumors, degenerative diseases of the brain, diabetes, inflammatory disorders of blood vessels (vasculitis), drug abuse, alcohol abuse, withdrawal from anti-anxiety or antidepressant drugs, traumatic injury to the brain, and occupational exposure to chemicals. Most seizures that occur as a single episode are grand mal seizures.

Epilepsy is the diagnosis given when an individual has repeated seizure episodes over time. In about 70% of new diagnoses of epilepsy, there is no apparent cause (Epilepsy Foundation).

Incidence and Prevalence: In the US, 300,000 individuals have their first convulsion each year, of which about 180,000 are adults. According to the Epilepsy Foundation, 10% of all Americans will experience at least one seizure during their lifetime. Only 20% to 25% or seizures are generalized grand mal type seizures; the rest are partial or localized seizures (Ko). About 3% of the population in the US is classified as having epilepsy, and active uncontrolled epilepsy occurs in less than 1% of individuals (Cavazos).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The vast majority of grand mal seizures are idiopathic. These seizures are rare in infants, but are more common in adults. In the elderly, they are often secondary to a localized brain lesion. Males are more likely than females to develop epilepsy, as are individuals over age 65, and blacks ("Epilepsy").

Source: Medical Disability Advisor



Diagnosis

History: Unless the healthcare provider witnesses an episode, a history of seizure from the family or other witnesses is important in diagnosis. Before a grand mal seizure, individuals may report warning symptoms (aura) such as smelling unpleasant odors or experiencing distortions of space and time. There may be a history of incontinence during the seizure, in addition to tongue biting or other self-injury. After a grand mal seizure, an individual often reports a severe, throbbing headache and / or severe fatigue. Between seizures, there may be a history of headaches, visual symptoms, weakness or numbness of an arm or leg, or speech disturbance. They provide important clues about the underlying cause and location of any structural defect in the brain.

If a grand mal seizure was the first seizure experienced, the individual may have had trauma to the head. Individuals may have diseases affecting the brain (i.e., meningitis), psychological stress, a history of taking mood-altering drugs (prescribed or illegal), or alcohol abuse. An important part of the history with a grand mal seizure is to discover if the generalized convulsion was preceded by a focal or partial seizure. This type of seizure can be limited to a single part of the body and then spreads or evolves into a grand mal seizure. This may imply dysfunction in a limited area of the brain related to birth injury, trauma, tumor, abscess, stroke, abnormal vessels (vascular malformation), or some other structural abnormality.

Physical exam: The immediate concern of the physician or emergency personnel first examining the individual is to make sure the individual's airway is open and unobstructed. If fever is noted, it could be the cause of the seizure or a sign of infection especially in infants and children. Any contusions, lacerations, or fractured bones the individual may have sustained during the seizure are noted. A brief neurological examination is performed. A more thorough examination is postponed until the individual is alert and able to follow directions. After the seizure (post-ictal phase), some neurological findings may be absent or equivocal. When the individual regains consciousness, he or she may not react appropriately to stimuli and may be temporarily paralyzed on one side (Todd's post-ictal paralysis). The neurological exam usually focuses on finding specific, localized neurological deficits that may indicate areas of brain lesions.

Tests: Blood tests can detect any metabolic abnormalities. A drug screen, including a blood alcohol level, may be warranted. If the seizure was preceded by fever or a change in mental status, an immediate spinal tap (lumbar puncture) is performed to check the spinal fluid for signs of an infection (meningitis, encephalitis) that may have led to a generalized seizure. However, if signs of increased pressure within the skull (increased intracranial pressure) are evident, brain CT or MRI should be done first. Further testing depends on whether or not this was the first seizure the individual has had. If it is the first episode without an apparent cause, extensive testing is necessary.

An electroencephalogram (EEG) may show characteristic changes or electrical abnormalities in the region(s) of the brain where the seizure began. If EEG is normal, longer periods of EEG monitoring in an overnight sleep laboratory or the use of a tape recorder (telemetry) to monitor brain wave activity during daily activities may be helpful. Other tests include cerebral angiogram to rule out aneurysm or arteriovenous malformation. In some cases, positron emission tomography (PET) can help determine whether the individual suffering recurrent grand mal seizures is a candidate for surgery, since this test helps localize the area of the brain where seizures originate.

Source: Medical Disability Advisor



Treatment

When an individual is brought to the emergency room during or following a grand mal seizure, airway and circulation must first be protected, and then any associated injuries or medical problems (i.e., stroke, drug overdose or withdrawal, infection, or complications of diabetes) must be treated. The individual should be protected from self-injury. Cardiopulmonary resuscitation (CPR) may be needed in some cases. If the seizure is ongoing, thiamine and sugar solution (glucose) should be given intravenously. Both thiamine deficiency and low blood sugar (hypoglycemia) can cause grand mal seizure and are easily treated with no side effects.

A single idiopathic seizure is generally not treated, although the individual should be tested extensively and followed closely. If the individual had only one grand mal seizure as a result of an illness in the brain, the illness is treated. Generally, no further treatment is necessary once the illness resolves.

When the seizure is caused by a structural problem in the brain that cannot be treated, the individual is at risk for continued seizures and may need ongoing medical treatment. An individual with ongoing grand mal seizures is treated with anticonvulsant drugs, either individually or in combination. Side effects and continued seizures despite drug therapy may necessitate frequent changes in the drug regimen. Depending on the cause of the seizure and if no seizures occur for 2 to 3 years, the medication dose may be reduced or stopped. Prolonged or repeated seizures (when the individual does not regain consciousness) denote a condition called status epilepticus that can be fatal without emergency treatment using intravenous anticonvulsant drugs.

Surgery is only considered if the individual has daily grand mal seizures, if the part of the brain where the seizure originates is known, and if quality of life is affected because of the constant seizures or the side effects from the anticonvulsant drugs. If the cause can be localized with certainty to a specific area of the brain such as the temporal lobe, the area can be removed surgically. Seizures may respond to surgery that cuts connections between the two halves (hemispheres) of the brain (corpus callosotomy). Brain damage may complicate epilepsy surgery and thus should only be used in intractable cases.

Source: Medical Disability Advisor



Prognosis

An individual who experiences a single grand mal seizure for which treatment was considered unnecessary will most likely never have another one. An individual with grand mal seizures that are well controlled with anticonvulsant drugs can lead a reasonably normal life. About 70% of individuals with epilepsy can expect to enter remission, which is defined as five or more years without seizures while taking medication ("Epilepsy").

The individual treated with surgery (who had part of the brain removed) may no longer need anticonvulsant drugs but may suffer from subtle impairments related to loss of brain structures, such as memory loss, language difficulties, or detrimental changes in personality, emotions, or behavior. Brain surgery stops recurrent seizures in most individuals and reduces seizures in most others. About 10% of individuals have uncontrollable seizures despite optimum medical management ("Epilepsy").

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Internal Medicine Physician
  • Neurologist
  • Neurosurgeon
  • Radiologist

Source: Medical Disability Advisor



Rehabilitation

The individual with epilepsy and recurring grand mal seizures will always be under the care of a neurologist. The neurologist monitors drug therapy to make sure the drugs reduce the frequency and intensity of the seizures and ensures that any other drugs the individual is taking do not adversely interact with the anti-seizure drugs.

Occupational therapy and / or physical therapy may only be necessary if the individual becomes partially paralyzed due to a severe head injury sustained during the grand mal seizure.

Source: Medical Disability Advisor



Comorbid Conditions

  • Cancer
  • Meningitis
  • Other neurologic conditions

Source: Medical Disability Advisor



Complications

Although very few people die of seizures themselves, a single grand mal seizure while driving a car, flying an airplane, or swimming alone can instigate a fatal accident. Operating a car, other vehicle, or heavy machinery when having a seizure can injure the individual and others. Constant seizures (some individuals have more than 50 per day) decrease the quality of life. Tongue biting, limb fracture, head trauma, and other injuries may accompany grand mal seizures. The lack of oxygen and blood flow to the brain during repeated seizures or status epilepticus can cause brain damage. During a seizure, the individual may choke on saliva or stomach contents (aspiration) that can lead to loss of oxygen or pneumonia.

Source: Medical Disability Advisor



Factors Influencing Duration

The main factor influencing the length of disability is how rapidly and completely the individual can be stabilized, whether by anticonvulsant drugs or surgery. Side effects from anticonvulsant medications that may hinder return to work include dizziness, fatigue, and memory problems.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with recurrent seizures who are on drug therapy should not operate machinery or motor vehicles or work from heights. If work involves driving, flying, or piloting a boat, the individual may be advised to find another line of work. Individuals who have been seizure-free for a year or more and have permission from a neurologist should not be restricted in their work-related activities. Driving restrictions vary from state to state for individuals with epilepsy. No restrictions should be placed on individuals who have only had one seizure, if the cause of that seizure has been removed (e.g., if seizure was the result of discontinuing an anti-anxiety drug). Disruptions in sleep related to working night shifts or undue stress may exacerbate a tendency to have seizures and should be avoided if possible.

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 individual have any birth trauma or head injury? A central nervous system infection? Brain tumor or stroke?
  • Did individual ingest a toxic substance? Have a metabolic imbalance?
  • Has individual had a witnessed seizure? Has individual been injured during a seizure?
  • Does individual have an aura?
  • Do headaches, visual symptoms, extremity weakness, or speech disturbance occur between seizures?
  • How old was individual at onset of seizures?
  • Does individual currently have any psychological stress?
  • Has individual taken mood-altering drugs (prescribed or illegal)? Does individual abuse alcohol?
  • Was a blood test done? Drug screen, including blood alcohol? If fever is present, was a lumbar puncture done? Brain CT or MRI? EEG? Has individual had a cerebral angiogram or PET scan?
  • Is individual a candidate for surgery?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • If the seizure was a single idiopathic seizure, was the underlying cause treated?
  • Have the appropriate anticonvulsant drugs been prescribed? Does individual take them as prescribed? Has individual had blood levels done to insure the drugs are in the therapeutic range?
  • Has surgery become necessary?

Regarding prognosis:

  • Does individual see a neurologist on a regular basis?
  • Does individual have any conditions that may affect the ability to recover?
  • Has individual had a seizure while driving a car or flying an airplane? Was license to do these things revoked?
  • If seizures cannot be controlled on anticonvulsant drugs, should surgery be considered?

Source: Medical Disability Advisor



References

Cited

"Epilepsy and Seizure Statistics." Epilepsy Foundation. 2003. 24 Oct. 2004 <http://www.epilepsyfoundation.org/answerplace/statistics.cfm>.

Cavazon, Jose E., Frank Lum, and M. R. Spitz. "Seizures and Epilepsy: Overview and Classification." eMedicine. Eds. Ramon Diaz-Arrastia, et al. 18 Oct. 2004. Medscape. 24 Oct. 2004 <http://emedicine.com/neuro/topic415.htm>.

Ko, David Y., and Soma Sahai-Srivastava. "Tonic-Clonic Seizures." eMedicine. Eds. Ramon Diaz-Arrastia, et al. 18 Oct. 2004. Medscape. 24 Oct. 2004 <http://emedicine.com/neuro/topic376.htm>.

Source: Medical Disability Advisor