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.

Non-Hodgkin Lymphoma


Related Terms

  • Mature B-cell neoplasms
  • Mature B-cell: Burkitt lymphoma
  • Mature B-cell: Diffuse large B-cell lymphoma
  • Mature B-cell: Follicular lymphoma
  • Mature B-cell: Lymphoplasmacytic lymphoma
  • Mature B-cell: Mantle cell lymphoma
  • Mature B-cell: Marginal zone B-cell lymphoma
  • Mature T-cell or NK-cell neoplasms
  • Mature T-cell or NK-cell: Adult T-cell lymphoma
  • Mature T-cell or NK-cell: Anaplastic large cell lymphoma
  • Mature T-cell or NK-cell: Peripheral T-Cell lymphoma
  • Mature T-cell or NK-cell: Primary cutaneous peripheral T-cell lymphoma
  • Precursor B-cell lymphoblastic lymphoma
  • Precursor T-cell lymphoblastic lymphoma

Differential Diagnosis

  • Benign tumors of the lymph system
  • Hodgkin disease
  • Human immunodeficiency virus (HIV)
  • Lymph node enlargement due to infection

Specialists

  • General Surgeon
  • Hematologist
  • Oncologist
  • Pain Medicine Physician/Pain Specialist
  • Pathologist
  • Radiology Oncologist

Comorbid Conditions

Factors Influencing Duration

The individual’s age, symptoms, performance status, and comorbidities may affect duration. Individuals older than 50 years tend to have more advanced disease and do less well in response to combination chemotherapy and radiation therapy than do younger individuals. The length of disability depends upon the stage of the disease when first detected, methods and complexity of treatment, and individual's response to treatment. Disability may result not only from the disease itself but also from the adverse effects of radiation or chemotherapy. Heavy physical labor is usually restricted for weeks to months following surgery, chemotherapy, and/or radiation therapy treatments.

Medical Codes

ICD-9-CM:
202.80 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Unspecified Site, Extranodal and Solid Organ Sites
202.81 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Lymph Nodes of Head, Face, and Neck
202.82 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Intrathoracic Lymph Nodes
202.83 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Intra-Abdominal Lymph Nodes
202.84 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Lymph Nodes of Axilla and Upper Limb
202.85 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Lymph Nodes of Inguinal Region and Lower Limb
202.86 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Intrapelvic Lymph Nodes
202.87 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Spleen
202.88 - Lymphoma, Other; Lymphoma (Malignant) NOS, Diffuse; Lymph Nodes of Multiple Sites

Overview

Lymphomas can be categorized as Hodgkin disease (5 different subtypes) and non-Hodgkin lymphoma (NHL). NHL is divided into many subtypes, each with different genetic and clinical characteristics, as well as responses to therapy. Through the years there have been at least 8 systems of nomenclature and classification, so many loose synonyms for these cancers still exist. The 2008 World Health Organization system is the most widely used and the recommended nomenclature, as it is based on modern understanding of the cell of origin of these cancers as determined by immunophenotype, cytogenetic, and molecular genetic testing (Swerdlow). Lymphomas develop from immune system cells that are intended to be in lymphoid tissue in the lymph nodes, thymus, tonsils, adenoids, intestine, and spleen, and that circulate normally in the blood stream. Thus any "lymphoma" can evolve into a leukemia illness, and any "leukemia" can develop a solid mass (lymphoma). Readers may need to consult the leukemia section of this resource for additional information.

Among all malignant lymphomas, including Hodgkin's disease, NHL represents 85% of cases, 5 times that of Hodgkin lymphoma. Most NHL primarily affects adults over age 60 (Vinjamaram).

In NHL, certain cell types (B- or T-lymphocytes and natural killer, or NK-cells) within the lymphatic tissue divide rapidly and replicate themselves uncontrollably, creating tumor masses that destroy the normal structure of lymph system vessels. NHL tends to spread (metastasize) quickly and invade other organs such as the spleen, liver, and bones. Some types of NHL metastasize to unusual areas such as the central nervous system and the digestive (gastrointestinal) tract.

Some lymphomas behave indolently, with the slow onset of symptoms, and with fluctuating symptoms over years. Other lymphomas behave very aggressively, with rapidly growing masses and, if not treated aggressively, death typically within weeks of diagnosis. A number of lymphoma related emergencies can occur including brain tumor (lymphoma mass), spinal cord compression, pericardial tamponade, vena cava compression, intestinal obstruction, and/or intussusception, due to a tumor mass. Emergencies related to the total tumor burden, and not just to one local tumor mass, include hypercalcemia, hyperuricemia, hyperviscosity syndrome. Other emergencies include lymphomatous meningitis, severe liver disease, and autoimmune hemolytic anemia and/or thrombocytopenia.

Incidence and Prevalence: The incidence for NHL is 19.5 per 100,000 men and women annually; an estimated 65,980 people are diagnosed each year, of which 35,990 are men and 29,990 are women (SEER). An increasing incidence since the 1970s is generally attributed to improved detection methods and the increase in HIV (Vinjamaram). The incidence increases with age, peaking after age 60.

NHL is the most prevalent hematologic neoplasm worldwide and represents about 4% of all cancers (Vinjamaram). Incidence rates are higher in developed countries.

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of developing non-Hodgkin's lymphoma increases with age; the median age at diagnosis is 67, including 1.7% diagnosed before age 20, 3.9% between ages 20 and 34, 7.2% between 35 and 44, 19% between 45 and 54, 22% between 55 and 64, 23.6% between 75 and 84, and 8.6% over age 85 (SEER). Men are at a slightly higher risk than women (the male-female ratio is 1.4:1), and whites are at a greater risk than blacks and Asian Americans (Vinjamaram)

Epstein-Barr virus, Human T-lymphocytic virus, type 1, and Human Herpes virus, type 8 are each associated with some types of lymphoma, and proteins made by these viruses appear to play a role in causation of the tumors. Human Immunodeficiency virus (HIV) is associated in that as it advances to AIDS the immunosuppressed state of the person removes the individual's natural tumor suppression function of the immune system. Thus the virus does not manufacture proteins that lead to the tumor, but damages the immune system that normally suppresses attempts of these tumors to form. This is the same as transplant patients, in whom the medications that prevent rejection of the transplant suppress the immune system to the degree that lymphomas are more common.

Risk factors for NHL also include exposure to toxic chemicals including vinyl chloride, herbicides (including dioxins, i.e. Agent Orange), pesticides, hair dyes and heavy metals, as well as ingestion of certain prescription cytotoxic drugs.

The lifetime risk is 2.09%, or about 1 in 48 men and women diagnosed during their lifetime (SEER).

Source: Medical Disability Advisor



Diagnosis

History: The most common presentation is with systemic symptoms, such as painless or slightly tender, swollen lymph nodes in the neck, underarm, or inner thigh (ilioinguinal), fatigue, weight loss, unexplained fever, and sometimes night sweats. Chest pain, coughing, or breathing difficulty may be reported. Some individuals may report itching of the skin. Gastrointestinal involvement may cause abdominal cramping or bloody diarrhea.

Local tumor masses can cause local symptoms, and individuals at times present with the symptoms of brain tumor, spinal cord compression, intestinal obstruction, obstruction of the ureter, and other problems. A history of immunosuppression because of a transplant or because of HIV may be present. The individual’s history may also include exposure to toxic chemicals and heavy metals or prior treatment with cytotoxic drugs (e.g. methotrexate for cancer, rheumatologic disease, or psoriasis).

Physical exam: Enlarged lymph nodes, nearly always in the neck region or armpit, but occasionally in the groin, are usually noted during physical examination. All areas where palpable lymph nodes normally occur are examined. Enlargement of both the spleen (splenomegaly) and liver (hepatomegaly) may be noticed during palpation of the abdomen. Tonsils may be enlarged as well. Bone tenderness or skin lesions may be noted. Some lymphomas produce skin masses.

Tests: Blood tests to look for leukemia or anemia associated with lymphoma include a complete blood count (CBC) to determine red blood cell (RBC) count, white blood cell (WBC) count, hemoglobin level, and platelet count. RBCs and hemoglobin are reduced if anemia is present secondary to bone marrow infiltration by cancer cells. WBC counts may be elevated as part of the immune system's response to disease or if a mixed lymphoma-leukemia status occurs. A stained peripheral blood smear (differential) may reveal an increased percentage of lymphocytes (lymphocytosis) and malignant cells common in the circulation with lymphomas. Blood chemistries may be performed to assess kidney and liver function, including blood protein (serum albumin), liver enzymes (serum lactate dehydrogenase [LDH], alanine aminotransferase [ALT], and aspartate aminotransferase [AST]), blood urea nitrogen (BUN), and electrolytes. HIV and HTLV testing are done. Hepatitis B and C serologies are obtained, as reactivation of hepatitis from immunosuppression during chemotherapy can be a severe complication, and prophylactic hepatitis treatment is frequently started just before the chemotherapy.

Definitive diagnosis of NHL requires a tissue biopsy of an enlarged lymph node or biopsies of other sites that are involved with a solid tumor, generally after imaging studies identify specific sites. A section of the tiny piece of tissue removed by needle biopsy will be stained (immunohistochemical staining) and then examined microscopically by a pathologist who will identify cell types. Once fine needle biopsy establishes that a lymphoma is present, excisional biopsy of an entire definitely enlarged lymph node is generally performed. The pathologist will be able to classify the disease. Flow cytometry studies may also be performed in addition to routine pathologic examination of cells. Typically a bone marrow biopsy will be done to help stage the disease.

Other tests may include routine x-rays, CT scans, MRIs, or PET scans (radiographic examination) of the chest, liver, and spleen, and possibly bones, to identify enlarged lymph nodes or lymphoma tumor masses.

A bone scan and/or bone marrow biopsy may be done to evaluate the extent of bone involvement. A lumbar puncture may be performed to obtain cerebrospinal fluid for microscopic examination looking for lymphomatous meningitis. If pleural fluid or ascites is present, that fluid will also be removed for testing.

Staging of the lymphoma is critical to selecting the appropriate treatment and determining the prognosis. It may require all the diagnostic and imaging tests described, especially CT scans of neck, chest, abdomen, and pelvis and bilateral bone marrow aspiration and biopsy. The four stages for NHL are stage I: a single node region or single extranodal site (outside lymph tissue); stage II: two or more nodal regions on the same side of the diaphragm or one extranodal site; stage III: nodal disease on both sides of diaphragm, or nodes on one side and extranodal involvement on the other side of the diaphragm; and stage IV: disseminated involvement of sites outside the lymph system such as liver, bone marrow, or multiple organ systems.

Source: Medical Disability Advisor



Treatment

Treatment will vary depending upon the type of NHL, the stage of the disease, the types of cells involved, and the organ systems involved in metastasis. Indolent stage I or stage II NHL, may receive radiotherapy and limited chemotherapy, or with full course extended chemotherapy. More aggressive and more advanced disease is generally treated with extensive chemotherapy.

Monoclonal antibody therapy has been viewed as a breakthrough in treating lymphoma; it works by targeting specific proteins on the lymphoma cell surface. Rituximab, a monoclonal antibody drug, has been reported to have a good response rate in patients with a high tumor burden who are not able to tolerate chemotherapy. It can increase the effectiveness of other treatments or can be used alone. This drug may penetrate the central nervous system and help with brain or spinal cord disease

The current “CHOP” (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen does not penetrate the blood-brain barrier and thus does not get into the central nervous system. Solid tumors in the brain or spinal cord, or lymphomatous meningitis require treatment with intrathecal chemotherapy, other chemotherapy agents intravenously, or localized radiation therapy.

Sometimes disease is localized and amenable to surgical resection (including involvement of a testicle, ovary, or small intestine).

Autologous bone marrow transplantation (autologous BMT) is sometimes used in patients who have relapsed after prior treatment. This procedure involves removing a portion of the affected individual's selected healthy bone marrow and storing it while chemotherapy or radiation treatment is administered to destroy cancerous cells. Later, the stored bone marrow is injected back into the individual's bone marrow (engraftment) with the objective of restoring normal cell production.

When other treatments have failed, the radioimmunotherapy drugs ibritumomab or tositumomab may be used; they are monoclonal antibodies combined with radioactive isotopes. However, this type of treatment is associated with reduced blood cell counts, hemorrhage, and severe infections.

Source: Medical Disability Advisor



Prognosis

Prognosis in adults varies widely and depends upon the type of NHL, the stage of the disease, whether it has just been diagnosed or has recurred, the organs affected by metastasis, the age and general condition of the individual, and the initial response to treatment. Individuals with low-grade lymphomas have a median survival rate of 5 to 10 years, those with intermediate-grade lymphomas have a median survival rate of 2 to 5 years, and individuals with high-grade lymphomas have a predicted median survival rate of less than 2 years (Vinjamaram). In advanced stages, the disease is not usually curable. Of the estimated 65,980 men and women diagnosed, 19,500 are predicted to die annually (SEER). In general, the overall survival rate is 50% to 60% at 5 years, and those with aggressive NHL have a 30% cure rate. Most recurrences of the disease occur within the first 2 years after treatment; however, if the histology of the lymphoma remains low-grade it can be re-treated with considerable success (Gajra).

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation is not usually an issue for patients with non-Hodgkin lymphoma.

Source: Medical Disability Advisor



Complications

Complications of non-Hodgkin's lymphoma may involve clinical emergencies due to lymph node enlargement or fluid accumulation in various locations in the body where obstruction may result, including obstruction of the airway, obstruction of the major vein that returns blood to the heart (superior vena cava obstruction), compression of the heart (pericardial tamponade), spinal cord compression, obstruction of the hepatic (liver) bile duct (extrahepatic biliary obstruction), or pressure on nerves in the head or periphery (cranial and peripheral neuropathies). Grossly enlarged lymph nodes in the neck and abdominal swelling from an enlarged spleen and/or liver may sometimes alter body appearance if the individual is not responding to therapy. Complications of radiation treatment for NHL are similar to those of radiation for Hodgkin's lymphoma, including development of acute nonlymphocytic leukemia, autoimmune hemolytic anemia, and radiation-induced carcinomas and sarcomas. Additionally, radiation therapy to the neck region may result in an underactive thyroid (hypothyroidism) several years after treatment is completed. Chemotherapy often results in acute, though reversible, toxicity leading to nausea, vomiting, and neurologic disorders. Infections may occur as a result of immunosuppression by chemotherapeutic agents being used in treatment or as a result of the disease itself. Other complications of chemotherapy may include heart or lung disorders and female or male infertility.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with non-Hodgkin's lymphoma of any type will experience high levels of fatigue with normal levels of physical exertion. Chemotherapy and radiation therapy can cause additional weakness and fatigue. Work responsibilities may need to be modified and heavy physical labor curtailed until recovery is complete. Caution must be used to protect the individual from contact with other individuals who have infection of any kind, and use of cutting instruments or sharp tools or machinery must be avoided to protect against skin puncture and potential bleeding.

Risk: According to "Work Ability and Return to Work," "Risk in cancer survivors may be due to chemotherapy. If there is physical exam or electrodiagnostic test evidence of chemotherapy associated peripheral neuropathy, balance may be impaired, and restrictions that would prevent climbing to heights may be indicated. If corticosteroids or chemotherapy have resulted in osteoporosis, restrictions to prevent pathologic fracture may be indicated (including limited climbing to heights and limited heavy lifting). As long as immune system suppression exists after treatment, patients should be restricted from working with sick animals or humans and from fungal exposure (e.g. gardening)" (406).

Capacity: According to "Work Ability and Return to Work," "Patients may have residual myopathy after chemotherapy, and functional testing may be indicated to quantitate residual functional capacity. Some chemotherapy agents have cardiac and pulmonary toxicity, and treadmill testing of exercise ability may be helpful to establish current ability. Similarly, some cancer surgery (eg, pneumonectomy) will decrease cardiopulmonary function (capacity for work or exercise). Similarly, anemia may be significant during and after chemotherapy, and treadmill exercise testing can give both the physician and the patient an idea about exercise or work capacity" (406-407).

Tolerance: Tolerance issues tend to predominate, especially after normal expected surgical healing. Chemotherapy can have effects on functioning which limits tolerance for the work environment. Ideally, reduced work hours may accommodate that limitation while creating a permissive environment of eventual return to work. According to "Work Ability and Return to Work," "Patients undergoing chemotherapy and/or radiation therapy typically have symptoms like nausea, diarrhea, and fatigue that are clearly due to their treatment, and in Western society these symptoms are traditionally judged to be severe enough to justify certification of work absence during the active phase of cancer treatment. Despite these symptoms, many of the self-employed and uninsured return to work" (407).

Source: Medical Disability Advisor



Maximum Medical Improvement

Individuals undergoing chemotherapy are not at MMI until 90 days post-chemo.

Individuals who require surgery only would be at MMI at 90 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:

  • Was the diagnosis of NON-Hodgkin Lymphoma confirmed by biopsy?
  • What subtype disease has been established?
  • What stage is the disease?

Regarding treatment:

  • Is the individual receiving appropriate chemotherapy and/or radiation therapy under the direction of a hematologist or oncologist?
  • Were these treatments successful?
  • If not, is individual a candidate for autologous bone marrow transplantation?

Regarding prognosis:

  • What is the type of NHL, stage of the disease, and age of the individual?
  • Is this an initial diagnosis or a recurrence?
  • Is there still disease present after completing the usual chemotherapy?
  • Is the brain or spinal cord involved?
  • Has individual experienced complications from the disease?
  • Has individual experienced complications associated with radiation therapy, such as radiation-induced secondary cancer or hypothyroidism?
  • Has toxicity from chemotherapy treatments occurred, resulting in nausea, vomiting, or neurologic disorders?
  • Has individual experienced frequent or prolonged infection as a result of immunosuppression?
  • What is the treatment plan for the complication, and what is the expected outcome after treatment?

Source: Medical Disability Advisor



References

Cited

"SEER Stat Fact Sheets: Non-Hodgkin Lymphoma." National Cancer Institute. 2011. New Media Systems, LLC. 20 Mar. 2013 <http://seer.cancer.gov/statfacts/html/nhl.html>.

Gajra, Ajeet, and Neerja Vajpayee. "B-Cell Lymphoma." eMedicine. Eds. Emmanuel C. Bessa, et al. 30 Jan. 2012. Medscape. 12 Mar. 2013 <http://emedicine.medscape.com/article/202677-overview>.

Swerdlow, S. H. , et al., eds. World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues. International Agency for Research on Cancer, 2008.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Vinjamaram, Sanjay, et al. "Lymphoma, Non-Hodgkin." eMedicine. Eds. Krishnan Koyamongalath, et al. 11 Mar. 2013. Medscape. 20 Mar. 2013 <http://emedicine.medscape.com/article/203399-overview>.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.