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.

Multiple Myeloma


Related Terms

  • Multiple Myelomatosis
  • Plasma Cell Myeloma

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • General Surgeon
  • Hematologist
  • Nephrologist
  • Oncologist
  • Orthopedic (Orthopaedic) Surgeon
  • Radiology Oncologist

Comorbid Conditions

  • Blood diseases
  • Diabetes
  • Immune disorders
  • Systemic infection

Factors Influencing Duration

Length of disability is determined by the severity of symptoms, stage of disease, advanced age, complications of the disease, and response to treatment.

Medical Codes

ICD-9-CM:
203.00 - Multiple Myeloma without Mention of Having Achieved Remission; Failed Remission
203.01 - Multiple Myeloma; Kahlers Disease, Myelomatosis; in Remission
203.02 - Multiple myeloma, in relapse

Overview

Multiple myeloma is an aggressive, cancerous (malignant) condition characterized by the overproduction of plasma cells in bone marrow, which cluster to form plasma cell tumors (marrow plasmacytomas). Plasma cells and antibody (immunoglobulin) production are important components of the body's immune system. Normal plasma cells are a type of white blood cell (mature B lymphocytes, or B cells) that respond to an invading organism (viral or bacterial) by producing antibodies, also known as immunoglobulins, against it. The types of immunoglobulin include IgE, IgG, IgM, IgA, and IgD. Each immunoglobulin molecule typically consists of two heavy chains and two light chains of proteins (polypeptides). In multiple myeloma, the abnormal plasma cells overproduce immunoglobulin G (IgG), immunoglobulin A (IgA), and/or light chains (portions of immunoglobulin). As certain types of immunoglobulin (IgG, IgA) are overproduced, other types are underproduced, which may impair immune function. In some cases of myeloma, an abnormal light chain called Bence Jones protein is precipitated out into the urine and serves as a diagnostic indication of myeloma.

Since healthy plasma cells are known to have a limited ability to divide and multiply, it has not been clearly understood how tumor plasma cells overproduce in myeloma. However, studies have shown there is a unique type of immature B lymphocyte (B cell) commonly found in myeloma that divides rapidly. Although normal B cells mature into functional plasma cells, these unique B cells may behave as tumor stem cells (malignant B cells) that overproduce the new myeloma cells and eventually form marrow plasmacytomas. Plasmacytomas are typically found in the bones of individuals with multiple myeloma and can occasionally be found in other organs, particularly in the lungs.

Four conditions typically develop as multiple myeloma progresses: anemia, problems with kidney function (renal damage), frequent bacterial infections, and bone loss. As healthy bone marrow is replaced by malignant plasma cells, there is reduced production of normally functioning red blood cells, which can result in anemia. Casts of discarded cells form in the tiny tubules of the kidneys and impair kidney function. Recurrent infection is also typical as the immune function becomes compromised by lack of necessary immunoglobulins and functioning white blood cells. Expansion of plasma cell tumors within the bone destroys bone tissue and can result in osteoporosis that can cause spontaneous fractures and spinal cord compression. Bone lesions (osteolytic lesions) may also develop because of a factor (osteoclast-activating factor) that is released by the myeloma cells. Calcium is released into the bloodstream, reducing bone stores of calcium while increasing the level of calcium circulating in the blood (hypercalcemia). This circulating calcium is not able to be utilized by the body, and its presence is another indication of the disease.

Incidence and Prevalence: Multiple myeloma occurs most often in older individuals with peak incidence at age 69. It is rare before the age of 40. The incidence of multiple myeloma is 4 in 100,000 individuals, slightly more in males than in females. The incidence in blacks is twice that in whites.

Source: Medical Disability Advisor



Causation and Known Risk Factors

The exact cause of multiple myeloma is not known. Genetic causes are indicated by abnormal cell growth (morphology) in the presence of certain chromosome abnormalities. Individuals who have been diagnosed with a premalignant condition called "monoclonal gammopathy of undetermined significance" (MGUS) are at increased risk for developing multiple myeloma. Theories suggest that exposure to herbicides or radiation may increase risk. Individuals who produce antibodies that react against the body's own tissues (autoimmune disease) are at greater risk for multiple myeloma.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report pain in their bones especially the back (spinal vertebrae), hips or pelvis, ribs, and skull. If the vertebrae are affected, they may collapse and compress nerves, causing numbness or paralysis. Individuals may have a history of recurrent bacterial infections. A report of increased fatigue and shortness of breath upon exertion may indicate anemia. Nausea, confusion, frequent urination (polyuria), and constipation may be present due to an increased circulating calcium level (hypercalcemia) or because of pending renal failure.

Physical exam: A complete physical exam may reveal pallor, tenderness with pressure over an involved bone, and, in rare instances, soft tissue masses. Cardiac examination can show an abnormal heartbeat related to anemia, excessive amount of potassium in the blood (hyperkalemia), or amyloid heart disease. Neurologic exam may give evidence of nerve disorder (neuropathy) or spinal cord compression. Carpal tunnel syndrome may be present in the wrist. Enlargement of the liver or spleen may be noted on palpation of the abdomen.

Tests: A complete blood count (CBC) will typically indicate decreased red blood cells (anemia), hemoglobin, and cell volume. An erythrocyte sedimentation rate (ESR) may be done, with increases indicating inflammation or infection.

Blood chemistry tests will identify excess protein in the form of free light chain portions of immunoglobulins or monoclonal immunoglobulins (levels of IgG or IgA), and abnormally high levels of calcium (hypercalcemia) indicating bone breakdown. Free immunoglobulin fractions (light chains) can also be detected in the urine as Bence Jones protein. Quantitative methods for measuring increases or decreases in the production of free light chains or immunoglobulins in serum or urine are helpful to both diagnose and monitor individuals with multiple myeloma. Serum electrophoresis identifies the specific overproduced immunoglobulins.

A DNA microarray technique can be used to study gene profiles and help identify the type of cells and antibodies that are proliferating. A bone marrow aspiration and biopsy will show increased numbers of plasma cells at varying stages of maturity; sheets or stacks of plasma cells will be seen microscopically. Chromosome studies may reveal acquired chromosome abnormalities that may help determine the individual's prognosis.

Source: Medical Disability Advisor



Treatment

Treatment is usually withheld until differential diagnoses are explored. Therapy for multiple myeloma includes simultaneous treatment of the disease and related complications. Treatment of the disease usually consists of high doses of a combination of anticancer drugs (chemotherapy) to effectively reduce the number of abnormal plasma cells. Sometimes non-cytotoxic (nonchemotherapeutic) drugs are also used such as interferon and glucocorticoids. Areas of diseased bone are often treated with radiation to help relieve pain and prevent fractures.

Anemia is treated with transfusion of packed red blood cells and medication to stimulate red cell production (hematopoietic therapy). Bacterial infections are treated with antibiotics. Skeletal damage may be prevented by monthly infusion of a drug that protects against bone loss. Maintaining ambulation is important to maintain bone quality as much as possible and to avoid or delay osteoporosis.

Treatment of associated complications such as hypercalcemia and renal failure may include a combination of increased fluid intake, hormone therapy (glucocorticoids), and chemotherapy. Pain relievers (analgesics) are often needed. Bone marrow transplantation may be performed in individuals younger than age 70. Transplanted marrow may be the individual's own treated marrow (autologous transplant) or from a matched sibling donor (allogeneic transplant).

Autologous peripheral stem cell transplantation is replacing bone marrow transplants as the treatment of choice, especially for patients older than age 70 who are in otherwise adequate health (Beers). In this treatment, the patient's own healthy red blood cells are obtained from their peripheral blood circulation and transplanted into their marrow to replace abnormal plasma cells.

Source: Medical Disability Advisor



Prognosis

With treatment, 60% of individuals improve in both quality of life and survival (Beers). The median survival time in symptomatic individuals after diagnosis is 30 to 36 months. The outcome is better for individuals who present with few, if any, symptoms. These individuals have a median survival of 10 years. Forty percent of individuals receiving a bone marrow transplant with their own marrow (autologous transplant) achieve regrowth of healthy bone marrow and experience a median post-transplant survival of 41 months. Thirty-six percent of individuals receiving marrow from a matched sibling donor (allogeneic transplant) achieve regrowth of healthy donor marrow. Stem cell transplant has higher mortality related to the treatment itself and the advanced age of the recipient. Transplant-related mortality in autologous transplants is about 7% and in allogeneic transplants, 25% to 40%. Almost all individuals eventually relapse. Fewer than 5% survive longer than 10 years.

Source: Medical Disability Advisor



Complications

Complications include increased risk of infection, destruction of bone tissue that may result in fractures or hypercalcemia with subsequent kidney failure, spinal cord compression with possible neurological impairment, and anemia or bleeding disorders.

A condition in which a substance containing protein and starch accumulates in tissues and organs (amyloidosis) occurs in approximately 15% of individuals with multiple myeloma.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Pain and weakness may make sedentary work and a shortened work schedule necessary.

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 pain in the bones, especially the vertebrae, pelvis, ribs, and skull?
  • Does individual have history of recurrent bacterial infections?
  • Does individual show symptoms such as nausea, confusion, frequent urination (polyuria), and constipation?
  • Were other conditions with similar symptoms such as MGUS, chronic lymphocytic leukemia, non-Hodgkin's lymphoma, primary amyloidosis, metastatic carcinoma, bone neoplasms, and macroglobulinemia ruled out?
  • Did CBC show anemia? Were blood chemistry tests performed? What were the results?
  • Has diagnosis of multiple myeloma been confirmed?

Regarding treatment:

  • Has chemotherapy been effective in slowing progression of the disease?
  • Has radiation therapy helped manage pain?
  • Are complications such as anemia or infections being effectively treated with blood transfusions and antibiotics, respectively?
  • Is individual a candidate for bone marrow transplant? Does individual have a matched sibling donor?
  • Is skeletal damage being prevented?
  • Are hypercalcemia and renal failure being treated with increased fluid intake, glucocorticoids, and chemotherapy?

Regarding prognosis:

  • Has treatment been effective in slowing progression of the disease?
  • Have complications been avoided or responded to treatment?
  • Is pain being adequately managed?
  • Did any complications occur such as infection, destruction of bone tissue, spinal cord compression with possible neurological impairment, kidney damage or failure due to increased levels of calcium released during bone destruction and excess immunoglobulin in the blood, or anemia or bleeding disorders?
  • Does individual have an underlying condition (other chronic disease such as diabetes, heart disease, kidney disease or lung disease) that may impact recovery?
  • Would individual benefit from psychological counseling or enrollment in a multiple myeloma support group?

Source: Medical Disability Advisor



References

Cited

Porter, Robert S., ed. "Multiple Myeloma." The Merck Manual of Diagnosis and Therapy. 19th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2011.

Source: Medical Disability Advisor






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