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.

Lyme Disease


Related Terms

  • Lyme Arthritis

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Dermatologist
  • Family Physician
  • Infectious Disease Internist
  • Neurologist
  • Orthopedic (Orthopaedic) Surgeon
  • Preventive Medicine Specialist
  • Rheumatologist

Comorbid Conditions

Factors Influencing Duration

The length of disability will be influenced by the severity of symptoms, the stage at which the disease is diagnosed and treated, and the presence of any neurologic or cardiac complications.

Medical Codes

ICD-9-CM:
088.81 - Arthropod-borne Diseases, Other Specified; Lyme Disease

Overview

Lyme disease is a bacterial infection caused by Borrelia burgdorferi. It is spread by a bite from an infected tick. The tick (Ixodes species) requires a blood meal and feeds primarily on white-tail deer and white-footed mice. After ingesting bacteria in the blood from infected animals, they become infected and then spread the bacteria to the next animal that they bite. The ticks also feed on human blood. To pass on the infection, a tick must be attached to the individual for 2 to 3 days. In Europe and Asia, Lyme disease is transmitted by Borrelia azfelii and Borrelia garinii.

Approximately 30% of individuals who have Lyme disease have been exposed to ticks or have been bitten by a mature tick. Although a full-grown tick is only one-half the size of a pencil eraser, most bites are from immature ticks (nymphs), which are only about the size of a poppy seed.

The many signs and symptoms of Lyme disease mimic other diseases, making it difficult to diagnose. The disease may have three stages, so symptoms of advanced disease can take months or even years to develop.

Incidence and Prevalence: In 2002, 23,763 cases of Lyme disease were reported ("Lyme Disease"). About 90% of cases are concentrated in three main geographic areas: the coastal and wooded regions of the Northeast, upper Middle-West, and Pacific Coast. The disease is not limited to rural settings, however, and is becoming increasingly common in suburban areas. Incidence is 7 per 100,000 in the US ("Lyme Disease"), but as high as 69.9 per 100,000 in Connecticut (Meyerhoff). Lyme disease is also found in Europe, particularly the Netherlands, Switzerland, Croatia, and parts of Italy.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Adults who are at highest risk for infection are between 30 and 55 years of age (Puotinen). Those who work outdoors or participate in outdoor recreation are more likely to become infected. Whites are affected more frequently, representing 76% of reported cases (Meyerhoff).

Individuals living in Connecticut, Rhode Island, New York, Pennsylvania, Delaware, New Jersey, Maryland, Massachusetts, and Wisconsin have the highest risk, with 92% of cases reported in these states (Dedeoglu). Overall risk of infection per tick bite is 1% (McGinley-Smith).

Source: Medical Disability Advisor



Diagnosis

History: Symptoms vary depending upon the stage of the disease and the length of time since exposure. Early symptoms may arise within 2 to 30 days; symptoms of heart, brain, or joint disease may appear several weeks or months after exposure. The disease may become chronic (tertiary stage) at any time within 2 years of the initial infection. Individuals sometimes do not seek treatment until the later stages develop because symptoms are variable, mimic symptoms from other diseases, and may appear at different times.

The individual may initially see a flat or slightly raised red dot at the site of the tick bite. Over several days this will gradually expand to several inches across; it is called erythema migrans. Sometimes the reddened area has a characteristic "bulls-eye" appearance with a red center, pale circular ring, and then another reddened area. This is called target erythema migrans and is present in 80% of infected individuals (McGinley-Smith). In about half of all cases, additional smaller red areas form. Flu-like symptoms such as fever, chills, extreme fatigue or lethargy, headache, itching, intermittent muscle pain, and mild neck stiffness usually develop next. If untreated, the symptoms of the first stage may disappear after a few weeks, making diagnosis difficult.

A second stage (secondary Lyme disease) may develop after a few weeks or months and can involve the bones and muscles (musculoskeletal system), nervous system, and/or heart. The most common symptom in this stage is joint pain, which occurs in 60% of cases. Intermittent or temporary joint pains are often followed by more intense pain and swelling of the knees and other large joints. Lasting weeks to months, these episodes of joint inflammation may be followed by periods during which symptoms lessen or disappear (remission). If left untreated, however, these joint symptoms can lead to persistent symptoms and disability. Neurologic symptoms at this stage may include constant headache, stiff neck, facial droop (facial nerve palsy) involving one (unilateral) or both (bilateral) sides of the face, muscle paralysis, and pain and weakness in the extremities and trunk. Heart problems resulting from disturbances in the heart's ability to contract (cardiac contractility) can cause the individual to feel dizzy, lightheaded, or faint (syncope).

The third (chronic, or tertiary Lyme disease) stage begins months to years after the initial tick bite. This stage is dominated by musculoskeletal and nervous system disorders. Pain in the large joints is more persistent and frequent, often lasting more than a year without remission. Impaired memory, difficulty concentrating, sleep disorders, and unusual or strange behavior are common complaints. Pain in the spine is often accompanied by tingling or shooting pains in the extremities.

Physical exam: Individuals may not seek treatment until later stages, as symptoms are variable and may appear at different times. In the early stage, a small, red, flat, or slightly raised skin lesion surrounded by a round, bulls-eye-like red rash with a pale center may be present. The rash will increase in size, then fade, and may reappear at another site. The area does not itch but may feel warm to the touch. Additional smaller red, round rashes may appear at other body sites. Symptoms of heart, joint, or brain disease will become apparent within several weeks or months. Heart abnormalities may include irregular heartbeat (arrhythmias) due to heart block. Joint inflammation usually does not correspond in size or amount to same joint on opposite sides of the body; the knee joint is most frequently involved. Exam may reveal impaired memory and difficulty concentrating, diminished touch sensation, stiff neck or back, and facial droop.

Tests: The diagnosis of Lyme disease can be confirmed by testing the blood for antibodies to the bacteria causing the disease. Test may be variable results depending on the stage of the disease and the individual's immune response. Infected individuals may not show antibodies during the first stage of the disease. In later stages, most individuals have antibodies. Routine laboratory tests are helpful by excluding other diseases that can mimic Lyme disease. The electrocardiogram (ECG) can show variable degrees of heart block. Skeletal x-rays can show joint damage and erosive changes due to chronic inflammation.

Source: Medical Disability Advisor



Treatment

Antibiotics are prescribed based on the disease stage and symptoms. Early intervention with antibiotic therapy is more than 90% effective (Dedeoglu). They can be taken for as long as 21 days to treat early stage infections or for a month or more when treating chronic inflammation. Over-the-counter pain relievers may reduce fever and inflammation. In more advanced disease stages, severe joint pain and inflammation may require treatment with nonsteroidal anti-inflammatory drugs or corticosteroids.

A temporary pacemaker may be needed for severe heart block. Since the heart block is temporary (transient), a permanent pacemaker is rarely required. Chronic joint inflammation that is resistant (refractory) to treatment may eventually require removal of the inflamed membrane lining the joint (arthroscopic synovectomy).

Source: Medical Disability Advisor



Prognosis

In some cases, the infection subsides spontaneously. If diagnosed in the early stages and treated promptly with antibiotics, response to treatment and prognosis is very good. With appropriate antibiotic therapy, the rash should begin to fade within a week. Later stages of the disease can take weeks or months to respond and can recur despite therapy. Individuals with later-stage disease may require long-term follow-up. Fifteen percent of untreated individuals develop neurologic disease, and 10% develop cardiac symptoms. Intermittent swelling of the joints occurs in up to 60% of untreated individuals (Dedeoglu).

The outcome of untreated disease is difficult to predict. Occasionally, the infections subside with no lasting effects, but more often untreated infections progress to chronic arthritis, resulting in partial or permanent disability. The prognosis for neurologic or cardiac complications varies with the severity of infection and response to treatment.

Source: Medical Disability Advisor



Rehabilitation

Individuals who contract Lyme disease may require physical and/or occupational therapy to address arthritis symptoms. The frequency and duration of therapy varies and is contingent upon the symptoms exhibited. Physical therapists instruct individuals in the use of modalities such as heating pads as needed for pain control and to decrease joint stiffness. Therapists instruct in gentle stretching and strengthening exercises for the affected joints. Individuals learn to perform these exercises independently to help reduce impairment due to arthritis. For those individuals who have arthritis in the fingers, wrist, and hand, occupational therapists can order adaptive equipment to decrease stress that these joints experience in daily activities.

Individuals who experience cardiac symptoms or neurological impairment in association with Lyme disease may require physical, occupational, and psychological therapy. Both physical and occupational therapy address decreased balance, strength, and range of motion. Physical therapists provide individuals with basic strengthening exercises for the arms, legs, and trunk and instruct individuals in low-impact aerobic exercise such as treadmill walking or swimming to increase strength and endurance. Individuals learn to monitor their pulse as well as their perceived exertion to ensure that exercise is performed within safe parameters. Individuals learn strategies for bed mobility, transferring from one position to another, and walking. Individuals who can walk but whose balance is decreased learn to use a cane, walker, or crutches to improve their gait pattern. Individuals may also be fitted with orthotic braces for the legs to help with muscular control. Those individuals who cannot walk learn to use a wheelchair. Individuals or their caregivers learn to stretch each joint to maintain adequate flexibility for walking, wheelchair propulsion, transferring, and self-care activities.

Occupational therapists instruct individuals to pace themselves when performing activities of daily living (ADLs) to conserve energy and reduce fatigue. Occupational therapists may recommend that individuals use adaptive equipment to decrease exertion and cardiac output with ADLs and instruct individuals in strategies to improve independence with self-care.

Psychological counseling from a licensed psychologist or psychiatrist may be also be necessary to help an individual cope with a loss of functional abilities in association with Lyme disease. Promoting psychological health allows for an individual to maintain hope and motivation during the recovery process.

Source: Medical Disability Advisor



Complications

The recurrence of infectious arthritis after antibiotic therapy or the development of chronic arthritis due to untreated infections may complicate the disease. Chronic arthritis may lead to joint stiffness and limitations in movement. Cardiac complications might include arrhythmias or severe heart block. Serious neurologic disorders (such as meningitis or encephalitis), and demyelinating disorders (similar to multiple sclerosis) have been associated with Lyme disease and can lead to permanent impairment and death.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

There are no restrictions for early stage disease, but accommodations may be required for neurological or arthritic damage due to chronic stage disease. The type and extent of accommodations will depend upon the nature and severity of symptoms. Partial or intermittent disability may be expected if the disease is allowed to progress.

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:

  • Has diagnosis of Lyme disease been confirmed?
  • Has individual experienced any complications, such as infectious arthritis, cardiac complications, serious neurologic disorders (such as meningitis or encephalitis), and demyelinating disorders (similar to multiple sclerosis)?
  • Does individual have an underlying condition that may impact recovery?
  • Is individual pregnant?

Regarding treatment:

  • Was individual compliant with antibiotic therapy, especially if long-term therapy was required?
  • If individual did not take antibiotics faithfully due to side effects from medication, can an alternative antibiotic be used instead?
  • Have medications such as nonsteroidal anti-inflammatory drugs or corticosteroids, been effective in relieving joint pain? If not, what other options are available?
  • Is individual a candidate for a pacemaker if a severe heart block is present? If not, at what point would this option be considered?
  • Is individual participating in a rehabilitation program (physical, occupational, psychological therapy)?

Regarding prognosis:

  • At what stage in the disease was it first diagnosed?
  • Did individual receive prompt and appropriate treatment for that stage of illness?
  • Have symptoms persisted despite treatment or is this episode a recurrence of the initial infection?
  • How long was the antibiotic therapy regimen?
  • Was individual compliant in taking prescribed medication?
  • Would individual benefit from extended therapy or change in antibiotics?
  • Is residual neurologic or cardiac impairment present? To what extent does impairment impact function?
  • How disabling is condition at present?
  • Would individual benefit from re-evaluation by infectious disease specialist or orthopedic surgeon?

Source: Medical Disability Advisor



References

Cited

"Lyme Disease." Centers for Disease Control and Prevention. 17 Nov. 2003. U.S. Department of Health and Human Services. 16 Dec. 2004 <http://www.cdc.gov/ncidod/dvbid/lyme/epi.htm>.

Dedeoglu, Fatma, and Robert P. Sundel. "Emergency Department Management of Lyme Disease." Clinical Pediatric Emergency Medicine 5 1 (2004): 54-54. MD Consult. Elsevier, Inc. 16 Dec. 2004 <http://home.mdconsult.com/das/journal/view/43303969-2/N/14465728?ja=404796&PAGE=1.html&sid=290674983&source=>.

McGinley-Smith, D. E., and Byran Tsao. "Dermatoses from Ticks." Journal of the American Academy of Dermatology 49 3 (2003): 363-392. MD Consult. Elsevier, Inc. 16 Dec. 2004 <http://home.mdconsult.com/das/journal/view/43303969-2/N/14051417?sid=290674983&source=MI>.

Meyerhoff, John. "Lyme Disease." eMedicine. Eds. Kristine M. Lohr, et al. 1 Oct. 2004. Medscape. 16 Dec. 2004 <http://emedicine.com/med/topic1346.htm>.

Puotinen, Julie L., and Eugene Y. Cheng. "Lyme Disease." eMedicine. Eds. Aashit K. Shah, et al. 2 Jul. 2004. Medscape. 16 Dec. 2004 <http://emedicine.com>.

Source: Medical Disability Advisor






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