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.

Hypertension


Related Terms

  • Benign Hypertension
  • Essential Hypertension
  • High Blood Pressure
  • Primary Hypertension

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Internal Medicine Physician
  • Radiologist

Comorbid Conditions

  • Cardiac arrhythmias
  • Cardiovascular disease
  • Diabetes
  • Kidney disease
  • Obesity

Factors Influencing Duration

Length of disability may be influenced by the cause and severity of the hypertension, response to treatment, and whether or not the individual is compliant with treatment recommendations for lifestyle changes and drug therapy. Complications may produce a period of disability. Certain types of employment, such as those jobs requiring a commercial drivers license (CDL) or pilots license, may require a longer duration.

Medical Codes

ICD-9-CM:
401.1 - High Blood Pressure, Benign

Overview

High blood pressure (hypertension) occurs when small arteries and arterioles become narrowed, causing blood to exert excessive pressure against the blood vessel walls and making the heart work harder. Although blood pressure varies during the day and frequently increases as a normal response to stress and physical activity, an individual with hypertension has high blood pressure even at rest. This type of primary, or essential, hypertension does not have an obvious direct cause, although it can be influenced by both heredity and lifestyle factors. The term benign hypertension is a historical misnomer for primary hypertension that is misleading and has fallen into disuse. Secondary hypertension is the result of an identifiable underlying disorder such as kidney disease (polycystic kidney disease, glomerular disease, renovascular hypertension), arteriosclerosis, and certain endocrine diseases (Cushing syndrome, aldosteronism, pheochromocytoma, hypothyroidism or hyperthyroidism, hyperparathyroidism); it may also be caused by medication side effects (analgesics, antidepressants, immunosuppressive drugs).

As many as 90% to 95% of all cases of hypertension are primary hypertension (Madhur). The remaining cases of hypertension are secondary hypertension.

Blood pressure (BP) is recorded as two numbers and is measured in millimeters of mercury (mmHg). The top number (systolic pressure) represents pressure in the arteries when the heart muscle contracts to pump blood. The bottom number (diastolic pressure) represents pressure in the arteries when the heart is relaxed between beats. According to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), normal blood pressure and stages of hypertension are categorized by the systolic and diastolic pressure readings taken at rest, based on the average of two or more readings taken on two or more visits after the initial screening measurement (Chobanian). Optimal (normal) blood pressure is a systolic BP less than 120 mmHg and a diastolic BP less than 80 mmHg (less than 120/80 mmHg). Prehypertension is a systolic BP between 120 to 139 mmHg or a diastolic BP between 80 to 89 mmHg. Stage I hypertension is defined as systolic BP between 140 and 159 mmHg or a diastolic BP between 90 to 99 mmHg, and Stage II hypertension occurs when systolic BP is greater than 160 mmHg or diastolic BP is greater than 100 mmHg.

Incidence and Prevalence: Hypertension is common disorder affecting approximately one-third of the adult US population. Rates of hypertension have increased over the past few decades. A nationally representative sample of American adults recorded increasing rates of hypertension from 23.9% in 1988–1994 to 29.0% in 2007–2008. The control of hypertension has also increased from 27.3% in 1988–1994 to 50.1% in 2007–2008 (Go). Over 70% of those aged 40 and older were aware of their condition but only about 45% of those aged 18 to 39 were aware (Egan).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Several genetic and environmental or lifestyle factors increase the risk of primary hypertension, including obesity, high dietary salt (sodium) intake, tobacco use, high-fat diet, excessive use of alcohol, stressful lifestyle, and lack of exercise. Primary hypertension also may be inherited; specific genetic risk factors include abnormalities in angiotensin-renin genes and inherited abnormalities of the sympathetic nervous system controlling heart rate, blood pressure, and blood vessel diameter. The increasing prevalence of obesity in the US seems to be driving the increase of hypertension (Egan).

Blacks have much higher rates of hypertension than whites or Hispanics. Diabetes and kidney disease also increase the risk of hypertension. Systolic blood pressure naturally increases with age, and over 60% of adults aged 50 and over may have primary hypertension (Egan). Older individuals may also exhibit isolated systolic hypertension, a condition where only the systolic BP is elevated, usually due to stiffening of the aorta with aging.

For more information refer to "Disease and Injury Causation," pages 237 to 261.

Source: Medical Disability Advisor



Diagnosis

History: For most individuals, primary hypertension causes no symptoms for years, and is consequently known as the "silent killer." Symptoms of severe hypertension or its complications may include headache, dizziness, racing or irregular heartbeat (tachycardia or arrhythmias), tiring easily, sexual dysfunction, nosebleeds (epistaxis), chest pain, or shortness of breath (dyspnea). As the disease progresses, damage to the brain, eyes, heart, and kidneys may occur. Family history may reveal hypertension, stroke, heart disease, kidney disease, or diabetes. Individuals may present with risk factors for hypertension such as tobacco use, high salt intake, obesity, sedentary lifestyle, and elevated cholesterol. Medication history may reveal use of medications that elevate blood pressure. Social history may suggest emotional or environmental factors that could affect blood pressure.

Physical exam: Because early primary hypertension does not cause notable symptoms, it usually is detected during a routine physical examination. Once hypertension is suspected, evaluation may include blood pressure readings recorded in both arms, repeated after the individual sits or lies down for five minutes (and at least 30 minutes after smoking or coffee ingestion). If an individual has a high reading, BP is measured again after 10 to 15 minutes, and then twice on at least two other days to make sure the high BP reading is consistent. Readings may need to be repeated at home; some individuals will have elevated BP in the doctor's office because of anxiety (white-coat syndrome). If BP is elevated, the neck veins may be swollen (distended), the thyroid or heart may be enlarged, and heart murmurs may be noted. The eyes are further evaluated with an ophthalmoscope (fundoscopy or fundus examination).

Tests: Laboratory tests are seldom used to diagnose primary hypertension. After hypertension is diagnosed, however, diagnostic testing such as routine blood and urine tests, as well as other pertinent tests, are performed when secondary hypertension (see above) is suspected. A chest x-ray, echocardiogram, and electrocardiogram (ECG) may be performed to evaluate heart size and function. A blood test for renin may identify increased production of angiotensin, a chemical that narrows blood vessels. High renin levels may predict heart attack (myocardial infarction) in individuals with hypertension. An exercise stress test performed on individuals with borderline elevated BP may predict risk of enlargement of the left side of the heart (left ventricular hypertrophy). Cardiac catheterization may be necessary to diagnose underlying coronary artery disease.

Source: Medical Disability Advisor



Treatment

According to current JNC treatment guidelines, goals for individuals with known primary hypertension are to maintain a BP less than 140/90 mmHg; for those with diabetes or kidney disease, BP should be lower than 130/80 mmHg ("JNC 7 Express").

Primary hypertension cannot be cured but can be treated to control the condition and prevent complications. Treatment of hypertension usually follows a progressive approach, each step being slightly more aggressive than the previous one until BP is controlled.

The first step includes lifestyle modifications in order to achieve and maintain a body mass index (BMI) of less than 25, exercise aerobically for an average of 30 minutes/day to maintain weight or 300 minutes/week to lose weight, restrict alcohol consumption to fewer than 1 to 2 drinks/day, limit non-narcotic pain medications to less than once/week, consume at least 400 micrograms/day of supplemental folic acid, and to follow the Dietary Approaches to Stop Hypertension (DASH) diet (NIH). The DASH diet is low in saturated fat and cholesterol, rich in whole grains, fruits and vegetables, and contains modest amounts of protein, preferably from fish, poultry, low-fat dairy, nuts, or soy products. This diet contains more than twice the amounts of potassium, calcium, and magnesium than the average American diet, and limits sodium intake (NIH).

If blood pressure is not controlled by lifestyle modifications, the next step of treatment is drug therapy; however, lifestyle modifications should be continued. Drug therapy usually begins with a thiazide diuretic to remove excess fluid or a beta-blocker to reduce the force of the heart's contractions. Angiotensin-receptor blockers (ARBs), angiotensin-converting enzyme (ACE) inhibitors, direct vasodilators, or calcium channel blockers also may be used to reduce the force of the heart's contractions, dilate arteries, and make it easier for the heart to pump blood through the body. The physician's choice of drugs depends on the individual's response and comorbid conditions, if any.

Treatment may be fine-tuned by increasing drug dosage, substituting a drug for another in the same class, or switching to a drug in a different class. If blood pressure still is not controlled, then adding a second or third agent to the drug regimen (combination drug therapy) is considered.

Source: Medical Disability Advisor



Prognosis

With appropriate lifestyle changes and the wide variety of drug therapy available, most individuals with hypertension can control the condition. A diet low in salt can reduce hypertension. An average of 1.5 to 2.3 grams of salt per day is recommended. Regular aerobic exercise for at least 30 minutes on most days may reduce BP (Roger). However, because hypertension rarely has symptoms and individuals do not feel sick, they may not feel compelled to make lifestyle changes or follow medication regimens (noncompliance). This can lead to further complications from hypertension.

The mortality rate among men, women, all age groups and every race/ethnicity is higher for those with hypertension compared to those without hypertension. The age-adjusted rate of death among adults aged 24 to 75 is 18.8 per 1000 person-years. The mortality rate is decreasing but the gap in mortality between hypertensive adults and normotensive adults remains the same in all categories. Among blacks, death from hypertension is still higher compared to whites but the rate is improving (Ford).

Source: Medical Disability Advisor



Rehabilitation

The principles of aerobic conditioning in physical therapy are used to develop a hypertension treatment program. Such a rehabilitation program occurs in several phases and follows a progression similar to that for other cardiac diseases because elevated blood pressure is always considered a risk for related cardiovascular disease.

Rehabilitation professionals experienced in cardiac rehabilitation often keep a daily log of the individual's BP, heart rate, and cardiac rhythm. Individuals with significantly high BP typically are monitored using electrocardiography (ECG) to record the continuous electrical activity of the heart muscle. During the initial rehabilitation stage, individuals are monitored for heart rate, heart rhythm, and BP while performing low-demand aerobic activities that use large muscle groups such as the lower extremities. Initial exercises usually include calisthenics of varying intensity such as marching in place or raising both arms overhead.

As rehabilitation progresses, more intensive exercises are introduced as tolerated in addition to recreational activities such as swimming and hiking. Light jogging or cycling are appropriate as long as the individual tolerates the rehabilitation program well. The program for primary hypertension then gradually advances to aerobic exercises to increase cardiovascular fitness. These exercises include walking briskly, running, jogging, swimming, climbing stairs, or bicycling. According to the American Heart Association, this type of aerobic activity will help keep hypertension under control. Throughout all stages of the rehabilitation program for hypertension, the healthcare team monitors the individual closely to assure that the heart rate slowly returns to normal after exercises.

Source: Medical Disability Advisor



Complications

Hypertension is worsened by uncontrolled lifestyle factors such as obesity, smoking, poor dietary habits, and sedentary habits. Increased blood pressure can damage the inner lining of the arteries leading to atherosclerosis or thickening of the walls of the arteries. This in turn leads to increased hypertension and heart disease as the heart becomes enlarged (hypertrophy).

Complications of untreated hypertension also include injury to vessels in several organ systems that may cause kidney failure, stroke, heart failure, aortic aneurysm, heart attack (myocardial infarction), peripheral artery disease, and impaired vision due to retinal damage at the back of the eye (retinopathy) (Chobanian). Hypertension precedes the development of heart failure in about 90% of patients and increases risk for heart failure 2 to 3 times (Chobanian). Long-term (chronic) hypertension may lead to decreased memory and dementia in the elderly. Women of childbearing age who have hypertension before they become pregnant are at greater risk for pre-eclampsia, a severe and sudden increase in blood pressure accompanied by significant proteinuria during pregnancy that can have serious consequences for both mother and fetus. If primary hypertension is untreated, it can lead to malignant hypertension with severe blood pressure elevations that can be life threatening.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or special accommodations usually are not required for individuals with mild cases of primary hypertension. Some individuals, however, may need a less stressful work environment.

For more information refer to "Work Ability and Return to Work," pages 267 to 271.

Risk: Risk is dependent on the degree of hypertension, as well as on the individual’s compliance with lifestyle modifications and any medications. Individuals working as commercial drivers with uncontrolled hypertension may need reassignment.

Capacity: Compliance with lifestyle modifications will improve capacity. Increased activity is of benefit to the individual. No reduction in capacity is anticipated for individuals with mild primary hypertension.

Tolerance: Hypertension does not typically cause symptoms. Individuals may need to monitor their blood pressure at the workplace during medication adjustments.

Source: Medical Disability Advisor



Maximum Medical Improvement

30 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 a family history of hypertension?
  • Does individual smoke, use salt generously, or have a sedentary lifestyle?
  • Is individual overweight? Obese?
  • Does individual complain of headache, dizziness, irregular heartbeat (arrhythmias), tiring easily, sexual dysfunction, nosebleeds (epistaxis), chest pain, or shortness of breath (dyspnea)?
  • Are medications or emotional or environmental factors contributing to hypertension?
  • Are blood pressure readings elevated consistently?
  • Has diagnosis of primary or secondary hypertension been confirmed?
  • Does individual have distension of neck veins, enlarged thyroid, heart murmur(s), or eye problems?
  • Has a urine analysis been done?
  • Have blood tests, including a test for renin been done?

Regarding treatment:

  • Has individual attempted to make lifestyle changes?
  • Does individual require assistance such as a weight loss program, counseling from a dietitian, an exercise regimen, or a smoking cessation program?
  • Is individual using the DASH diet?
  • What drug(s) has the individual taken? Has the dosage been increased?
  • Is another drug of the same class required?
  • Is a drug in a different class required?
  • Is noncompliance with the treatment regimen an issue?

Regarding prognosis:

  • Is individual adhering to recommended lifestyle changes and to the prescribed drug regimen?
  • Does individual understand the potential risks of untreated hypertension, including heart disease, stroke, heart attack, aortic aneurysm, and eye and kidney disease? If not, would education encourage compliance with recommended treatment?

Source: Medical Disability Advisor



References

Cited

"National High Blood Pressure Education Program." National Heart Lung and Blood Institute. Dec. 2003. U.S. National Institutes of Health. 16 Jun. 2014 <http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf>.

"Your Guide to Lowering your Blood Pressure with DASH." National Heart Lung and Blood Institute. Apr. 2006. U.S. National Institutes of Health. 16 Jun. 2014 <http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf>.

American Heart Association. "High Blood Pressure." American Heart Association. 29 May. 2014. American Heart Association, Inc. 18 Jun. 2014 <http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/About-High-Blood-Pressure_UCM_002050_Article.jsp>.

Chobanian, A. V. , et al. "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure." Hypertension 42 6 (2003): 1206-1252.

Egan, B. M. , et al. "U.S. Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, 1988-2008." The Journal of the American Medical Association 303 20 (2010): 2043-2050.

Ford, E. S. "Trends In Mortality From All Causes and Cardiovascular Disease Among Hypertensive and Nonhypertensive Adults in the United States." Circulation 123 16 (2011): 1737-1744.

Go, A. S. , et al. "Heart Disease and Stroke Statistics--2013 Update: A Report from the American Heart Association." Circulation 127 (2013): e6-e245.

Madhur, Meena S. , et al. "Hypertension." eMedicine. Eds. David J. Maron, et al. 31 Mar. 2014. Medscape. 18 Jun. 2014 <http://emedicine.medscape.com/article/241381-overview>.

Melhorn, J. Mark, and William Ackerman, eds. "Causation in Common Cardiovascular Problems." Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008. 237-261.

Roger, V. L. , et al. "Heart disease and stroke statistics--2012 update: a report from the American Heart Association." Circulation 125 (1) (2012): e2-e220.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. "Working with Common Cardiovascular Problems." Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011. 255-290.

Source: Medical Disability Advisor






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