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 Sclerosis


Related Terms

  • Disseminated Multiple Sclerosis
  • Disseminated Sclerosis
  • MS

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Neurologist
  • Occupational Therapist
  • Ophthalmologist
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Psychiatrist
  • Urologist

Comorbid Conditions

  • Depression
  • Obesity
  • Psychiatric disorders

Factors Influencing Duration

Factors that influence disability include the form of MS (primary progressive, remittent-relapsing, secondary progressive), response to treatment, severity and frequency of symptoms, relapses and exacerbations, degree of recovery from exacerbations, presence of complications, and any pre-existing mental or physical problems. The individual's specific work duties and requirements will also affect the length of disability.

Medical Codes

ICD-9-CM:
340 - Multiple Sclerosis

Overview

Multiple sclerosis (MS) is a progressive inflammatory disease of the central nervous system. It is the most common cause of neurologic disability in young adults, with onset generally occurring between ages 15 and 40 (Dangond). In MS, local areas of the fatty material (myelin) that surround and insulate nerve fibers in the brain and spinal cord become inflamed and the myelin sheath is destroyed (demyelinated). This demyelination results in lesions (plaques or sclerosis) in the white matter (nerve cell tissue) of the brain, brain stem, optic nerves, and spinal cord, which can slow or block nerve impulse conduction. Production of these lesions has been observed by MRI studies to be fairly constant; 5 to 10 lesions may develop each year, corresponding to development of 1 or 2 new clinical signs or symptoms (Dangond).

Early in the disease process, demyelination usually results in intermittent attacks of neurological deficits followed by periods during which symptoms lessen or disappear (relapsing-remitting MS). In females, relapses are especially common in the first 2 to 3 months following pregnancy. As lesions increase, loss of neurological function progresses and symptoms become more constant (secondary progressive MS). Instead of the relapsing-remitting pattern, some individuals develop primary progressive MS, in which nerve fiber loss progresses slowly and steadily from the beginning without significant remission, while neurologic deficits increase and ultimately lead to significant disability.

Diagnosis often is a considerable challenge because of the potential for a wide range of signs and symptoms. After exclusion of all other causes, criteria for diagnosis must include at least two neurologic events, occurring in more than one location within the central nervous system and separated in time by at least a month. Over the course of the disease, physicians may use the Kurtzke Expanded Disability Status Scale (EDSS) to measure disease progression by severity scores ranging from 0 for a normal neurologic exam to 10 for death related to MS (Dangond).

Although the primary cause is not known, MS is believed to be one of a group of diseases described as immune-mediated or autoimmune. In autoimmune disease, the immune system is activated by triggers such as environmental exposures or viral infection to attack the body's own cells as though they were foreign material. In MS, the focus of the immune system's specialized white cells and antibodies is the nerve cells of the central nervous system (CNS), resulting in nerve fiber inflammation that affects multiple organ systems throughout the body. Genetic factors may also contribute to development of MS, as first-degree relatives (children or siblings) of those with MS have been shown to have a 3% to 5% chance of developing the disease (Campagnolo).

MS is characterized by recurrent exacerbations (attacks, flares, relapses), during which time symptoms worsen or new symptoms appear. Exacerbation of symptoms may last from days to weeks. Temporary exacerbations lasting approximately 24 hours are known as "pseudoexacerbations" and are typically triggered by stress, fever, urinary tract infections, or hot weather. Exacerbations may be minimized through anti-inflammatory therapy or plasmapheresis, a treatment that involves removing a quantity of blood, discarding the plasma, and returning the red blood cells to the individual. However, the secondary progressive phase of MS does not respond as well to treatment as the earlier relapsing phase.

Incidence and Prevalence: MS is the most common chronic neurological disease causing disability. It affects 400,000 individuals in the US, with 10,000 new cases diagnosed annually (Dangond). Incidence is highest among white populations in northern latitudes (Dangond). In high-risk areas, and for white North Americans, the prevalence is about 1 case per 1,000 people; prevalence is less among black and Asian Americans (Campagnolo).

MS occurs in all races but at different rates, affecting about 2.5 million individuals worldwide (Dangond).

Source: Medical Disability Advisor



Causation and Known Risk Factors

A history of viral infection or exposure to environmental toxins may be the trigger that increases risk of developing MS in those with genetic predisposition (Campagnolo). Since MS is 5 times more common in temperate zones (e.g., US, Canada, Europe) than in the tropics, environment is believed to play a part in initiating the disease. Living in or moving to a high-risk area before age 15 correlates with increased risk of developing MS, which also supports the idea of an environmental factor (Dangond).

MS generally develops in individuals between 15 and 45 years of age; the average age at diagnosis is 29 years in women, and 31 years in men (Campagnolo). Women outnumber men by a ratio of 2:1; this ratio is more balanced among those who develop symptoms at a later age (Campagnolo). Disease severity is believed to vary according to racial and geographic differences, with whites of northern European descent afflicted more than twice as often as other races (Dangond).

Source: Medical Disability Advisor



Diagnosis

History: Because MS can disrupt function in any area of CNS, symptoms are varied, numerous, and of differing severity and duration. Symptoms may come and go, making it difficult for the individual to describe them. Approximately half of individuals will report visual problems, including blurred or double vision, red-green color distortion, or loss of vision in one eye. Other common symptoms include severe fatigue; muscle weakness in the extremities; numbness, tingling, and loss of sensation (paresthesias); unsteady or abnormal limb movements and positioning; loss of coordination; loss of balance or equilibrium; a characteristically slow, short stride; impaired dexterity; urinary problems; disturbed speech patterns; mental and emotional disturbances; impaired thermal sensation; muscle stiffness and spasms; tremor; and dizziness. Many individuals with MS will report fatigue that worsens with high temperatures, hot showers, or strenuous exercise. Eye problems (optic nerve dysfunction) also may increase in these circumstances (Dangond). Urinary retention and impotence also are commonly reported.

Cognitive problems with attention span, concentration, memory, and judgment may be noted at any time during the course of the disease. Depression is common. Over the course of the disease some individuals with MS may develop overt psychiatric disorders such as bipolar disorder or paranoia. Individuals also may report emotional instability with periods of uncontrolled crying or laughing.

Physical exam: Physical findings are variable depending on which region of the CNS is involved and the stage of MS at presentation. Facial palsy may be noted. When inflammation occurs in the portion of the brain involved with vision, the eye's pupillary response to light often is diminished and optic nerve inflammation (optic neuritis) may be noted. Involuntary movements of the eye (nystagmus) may be present. Clumsiness, muscle weakness, and unsteady gait may be observed due to damage to nerve cell tissue in the brain. Disability may range from minimal (unsteady gait) to moderate (ambulatory with assistance) in the early phase, or symptoms may be absent if the MS is of the remitting-relapsing form. Inflammation of the spinal cord may result in observation of extremity weakness or stiffness. Evaluation of cognitive function may reveal slow mental functioning, short attention span, and lack of judgment. Depression and exaggerated fears or anxiety may be observed, possibly indicative of a psychiatric mood disorder known to occur in conjunction with MS. Full psychiatric evaluation may be needed.

Tests: There is no specific diagnostic test for MS, but the accuracy of the diagnosis can be improved with several indicators. A spinal tap to obtain a sample of cerebrospinal fluid (CSF) may be used to confirm the presence of an inflammatory lesion or to rule out other possible CNS diseases or infections. Recording nerve responses to various visual or auditory stimuli (evoked potentials) is routinely employed; absence of response or an abnormality in response is useful in detecting and localizing lesions in the CNS. Laboratory studies used to rule out other types of diseases include a complete blood count (CBC), serum glucose and serum electrolyte levels, blood clotting ability (coagulation studies), and urinalysis. Study of brain waves (electroencephalogram [EEG]) is abnormal in about one-third of individuals who have MS.

MRI is more sensitive and specific in diagnosing MS than other imaging modalities; it is able to reveal the presence of demyelinating plaques in 95% of individuals with MS (Dangond). It also is helpful in excluding other CNS disorders. Two types of magnetic resonance imaging (T1 MRI and T2 MRI) are used to both diagnose and monitor the disease. T2 MRI can identify the presence of MS lesions, while the T1 MRI with a pre-scan injection of gadolinium distinguishes “active” new lesions from old ones. Special MRI studies, such as magnetization transfer ratio (MTR), fluid attenuated inversion recovery (FLAIR), and magnetic resonance spectroscopy (MRS), are used to evaluate MS heterogeneity, predict prognosis, and study effects of treatment (Dangond). MRI findings often support a preliminary diagnosis, of which 50% will progress to clinically definite MS within 2 years; however, 5% of suspected individuals with normal MRI findings will similarly progress to MS (Dangond). Periodic testing and close monitoring, generally for years, is necessary.

Source: Medical Disability Advisor



Treatment

Search for a cure is still in progress. Treatment is directed at reducing acute exacerbations, modifying the disease process, lessening symptoms, and improving daily living. Treatment includes the use of anti-inflammatory drugs (e.g., corticosteroids, beta-interferon) or a combination of corticosteroid and immunosuppressant drugs. Newer drugs include glatiramer, which blocks the immune system attack on myelin, and natalizumab, which is designed to prevent damaging immune system cells from reaching the brain and spinal cord. Research on the immunomodulatory effects of statins when given in combination with interferons shows promise toward decreasing the production of new MS lesions, but no definitive evidence supports use of statins at this time (2009) and studies continue (Lock). Procedures such as plasmapheresis that can remove damaging immune system cells and antibodies are also used.

Studies of supplemental vitamin D in MS patients have shown a protective effect in reducing acute exacerbations and relapse. In a study at the University of Toronto, 16% of individuals taking high-dose vitamin D showed a significant reductions in MS exacerbations and had 41% fewer relapses, while 40% of those with modest dosage had relapses (Laine). Conclusions of this and other studies of vitamin D supplementation in MS have not yet been widely accepted.

MS symptoms can be treated with drugs to address muscle weakness and spasticity, physical therapy to strengthen weakened muscles, occupational therapy to teach individuals how to deal with neurologic deficits and disability both in the workplace and at home, and speech therapy to improve swallowing and communication. Treatment also targets bladder, bowel, and sexual dysfunction, and pain management. Stress management may help to reduce acute exacerbations. One of the most difficult aspects for the individual with MS is the sense of uncertainty about the course of the disease. Psychiatric or psychological counseling may be necessary to provide support.

Source: Medical Disability Advisor



Prognosis

The majority of young individuals with MS can lead active and productive lives for years, but in some MS may progress rapidly, disabling the person by early adulthood or causing death from complications within months of onset. Deaths are usually not due to MS but attributable to secondary illnesses such as recurrent infection, particularly in those who are confined to bed. However, the course of the disease and the rate of disability vary considerably from person to person. Some individuals may have periods of acute exacerbation with prolonged full or partial remissions. While most individuals at least partially recover from the first attack, others gradually become more disabled, bedridden, and incontinent by early mid-life.

Source: Medical Disability Advisor



Rehabilitation

Individuals with the diagnosis of multiple sclerosis require a range of rehabilitation services due to the chronic and progressive nature of the disease. The frequency and duration of rehabilitation is contingent upon the severity of the symptoms. Because this disease is chronic and progressive, individuals will require rehabilitation at regular intervals throughout their lives.

Physical therapy addresses mobility techniques. Therapists instruct individuals in strategies for bed mobility, transferring position, and walking. Individuals who can walk but whose balance is compromised 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 muscle control. Therapists instruct individuals who are no longer ambulatory how to use a wheelchair and may order a wheelchair to fit the needs of the individual. Wheelchairs may have supportive padding to support correct sitting posture, pressure-relieving seat cushions to decrease the risk of pressure sores, and may be manually propelled or motorized. Individuals learn to shift their weight periodically while seated to relieve pressure through the buttocks and further prevent pressure sores.

Occupational therapy addresses any difficulties with activities of daily living (ADLs). Individuals learn strategies for dressing, bathing, and meal preparation that are geared toward their particular functional limitations. Because there is a large component of fatigue associated with this disease, individuals learn energy conservation techniques and strategies to complete tasks during the portion of the day when their energy level is highest. Occupational therapists may order adaptive equipment to facilitate independence with ADLs.

Both physical and occupational therapy address decreased balance, strength, and range of motion. Individuals and their caregivers learn to stretch each joint to maintain adequate flexibility for walking, wheelchair propulsion, transferring, and self-care activities. Therapists teach individuals exercises to maintain strength in the arms, legs, and trunk, and how to perform weight-shifting exercises to aid in transferring and walking. As individuals with MS tire easily with activity and in warm temperatures, exercise repetitions should be kept low with frequent rest periods, and all exercise should be performed in a cool room.

Speech therapy may be required for improved eating, swallowing, and speech. Due to fatigue, individuals may benefit from eating several smaller meals or eating their large meal at the time of day in which they have the highest energy level. Therapists instruct individuals in performing jaw, tongue, and lip exercises to facilitate chewing and communication. Different food and liquid consistencies may be recommended to assist the swallowing reflex. Individuals also learn to achieve sucking control and saliva production. Because shallow respiration often occurs in individuals with MS, speech therapists may teach diaphragmatic breathing and better sitting posture. Individuals learn to speak with greater clarity through activities such as sustained vocal expressions.

Individuals may require a consultation with a rehabilitation nurse and/or nutritionist who specializes in MS treatment if bowel and/or bladder function are compromised. Individuals learn to manipulate their diet to allow for better control of urination and defecation. Individuals who are urine incontinent may learn to self-catheterize at regular intervals to manage incontinence.

Individuals may benefit from ongoing consultation with a psychologist or psychiatrist to cope with the loss of functional and physical abilities and with depression or other psychiatric disorder that may occur. This may be particularly important for those individuals who require the assistance of a caregiver. Counseling also can help individuals focus on realistic therapy goals and to maintain motivation. Psychologists and psychiatrists may facilitate support groups in which individuals speak with others who are living with MS.

Source: Medical Disability Advisor



Complications

Complications include those related to symptoms such as extreme fatigue, deteriorating general health, urinary incontinence, frequent urinary tract infections, constipation or bowel incontinence, skin ulceration, painful muscle spasms and stiffness, paralysis, and depression or other mental health problems. Although MS is not in itself fatal, those who are severely disabled may die from the complications of being bedridden, including recurrent infections such as pneumonia, blood clot in the lungs (pulmonary embolism), infected open areas of the skin (decubitus ulcers), and suicide.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with relapsing-remittent MS may experience one to three exacerbations per year and more continuous symptoms if they have primary progressive or secondary progressive MS. During an exacerbation, individuals may require time away from work for physician visits and treatment. A change in work duties also may be needed, with accommodation to lighter work tasks or the ability to sit more frequently. More frequent rest periods may be needed.

The individual's workspace may need to be changed to accommodate a wheelchair and provide a safe environment. The individual's motor functions may be hampered, possibly requiring accommodation for access to work stations or use of equipment. The individual may be unable to perform tasks requiring physical strength or flexibility. Individuals who frequently experience pseudoexacerbations will require a cool working environment and frequent restroom breaks. Company policy on medication usage should be reviewed to determine if medication use is compatible with job safety and function.

In advanced cases of MS, the individual may require handicapped-accessible facilities that are compliant with the Americans with Disabilities Act (ADA). Other restrictions and accommodations will depend on the nature of the employment, and nature and severity of symptoms. The individual may require frequent rest periods or changes in work hours, start times, and length of the workday because of fatigue. Visual disturbances may also affect the ability to perform certain activities.

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 present with symptoms consistent with diagnosis of MS?
  • Does individual have a history or risk factors for development of MS such as being female of Northern European heritage, living in a temperate climate before age 15, or family history of MS?
  • Were appropriate diagnostic tests such as MRI, EEG, CSF analysis done to rule out other conditions and establish diagnosis of MS?
  • Has individual received consultation with the appropriate specialists?

Regarding treatment:

  • Were anti-inflammatory and immunosuppressant agents prescribed?
  • Were disease modifying drugs prescribed?
  • Is individual taking medication as prescribed?
  • Was plasmapheresis performed to reduce exacerbation of symptoms?
  • Has individual received physical, occupational, and/or speech therapy as indicated to help with activities of daily living?
  • Is individual receiving appropriate psychiatric and/or psychological counseling?

Regarding prognosis:

  • Based on severity and frequency of symptoms what is the expected course of the disease? Has progression been evaluated according to the Expanded Disability Status Scale (EDSS)?
  • How frequent are relapses?
  • Is there complete or partial recovery after an exacerbation?
  • Has individual had good response to the present treatment? If not, have more aggressive interventions been considered?
  • Is individual severely disabled or bedridden?
  • Has individual experienced any complications of immobility that may affect prognosis? Have these complications been addressed in the treatment plan?
  • Has workplace been evaluated by occupational therapist to implement accommodations as needed?

Source: Medical Disability Advisor



References

Cited

Campagnola, D., et al. "Multiple Sclerosis." eMedicine. Eds. Martin K. Childers, et al. 17 Jul. 2009. Medscape. 30 Jul. 2009 <http://emedicine.medscape.com/article/310965-overview>.

Dangond, Fernando. "Multiple Sclerosis." eMedicine. Eds. William J. Nowack, et al. 14 Apr. 2009. Medscape. 1 Jul. 2009 <http:// emedicine.medscape.com/article/1146199-overview>.

Laine, Charlene. "High doses of Vitamin D cut MS relapses." WebMD.com. 28 Apr. 2009. WebMD, LLC. 30 Jul. 2009 <http://www.webmd.com/multiple-sclerosis/news/20090428/high-doses-vitamin-d-cut-ms-relapses >.

Lock, Christopher, David C. Spencer, and Steven Karceski. "Are ‘Statins’ Beneficial or Harmful in Multiple Sclerosis?" Neurology 71 18 (2008): E54-E56. 27 Feb. 2014 <https://www.neurology.org/content/71/18/e54.full>.

Source: Medical Disability Advisor






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