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.

Polymyalgia Rheumatica


Related Terms

  • Inflammation of Bursa
  • Inflammation of Synovial Membrane
  • Inflammation of Tendon
  • PMR
  • Proximal Myalgia of Hip and Shoulder

Specialists

  • Immunologist
  • Occupational Therapist
  • Physical Therapist
  • Rheumatologist

Comorbid Conditions

Factors Influencing Duration

The response to treatment and development of complications can affect the length of disability. Compliance with treatment plans and follow-up care are essential to prevent relapses or flare-ups and complications of corticosteroid therapy, any of which could increase duration.

Medical Codes

ICD-9-CM:
725 - Polymyalgia Rheumatica

Overview

Polymyalgia rheumatica is an inflammatory syndrome that is characterized by pain and stiffness of the neck, shoulders, lower back, and hips. It is often accompanied by constitutional symptoms such as fever, weight loss, and feelings of uneasiness or discomfort. Individuals who have the syndrome complain of pain and stiffness severe enough to make routine tasks such as combing their hair or getting dressed quite difficult.

Inflammation of the bursa (bursitis), synovial membrane (synovitis), and tendon sheath (tenosynovitis) of the hip and shoulder are characteristic of polymyalgia rheumatica. The etiology is unknown, but the syndrome is believed to have an autoimmune component and does not appear to stem from any defect of muscle or joints. One explanation is that infection may trigger an exaggerated immune response, which in turn affects individuals with an inherited predisposition for developing the condition. About 15% of people diagnosed with polymyalgia develop temporal arteritis, also called giant cell arteritis (GCA); correspondingly, 50% of people with GCA also develop polymyalgia (Saad). Polymyalgia and temporal arteritis share several characteristics: they are positive for the human leukocyte antigen HLA-DR4, demonstrate systemic monocyte activation, and show a polymorphism in the region of the HLA-DRB1 gene, suggesting a genetic component. The two conditions also share so many symptoms that they may, in fact, be different facets of the same disease. Temporal arteritis affects the carotid arteries; it is characterized by severe headache and can lead to sudden blindness.

Incidence and Prevalence: In the US, the average incidence of polymyalgia is 52.5 individuals per 100,000 population age 50 and older and increases with advancing age; prevalence is reported to be 0.5% to 0.7% (Saad). Frequency varies internationally, with highest rate occurring in northern Europe (as high as 12.7 per 100,000 reported for Italy) (Saad).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Polymyalgia rheumatica affects primarily whites and is rare in other races. It appears to be more common in northern latitudes and occurs more frequently in individuals with a northern European ancestry. Age is a risk factor for polymyalgia; most cases of polymyalgia rheumatica appear in individuals older than 50 years (Saad). It is twice as common in women as in men (Nochimson).

Source: Medical Disability Advisor



Diagnosis

History: The individual may complain of pain and stiffness in the thighs, hips, upper arms, shoulders, upper torso, and neck that began abruptly or developed gradually over a long period. The stiffness is pronounced in the morning and after periods of inactivity. The individual may complain of difficulty rising from bed and the stiffness lasting for up to an hour. Pain is usually on both sides (bilateral). The individual often complains of fatigue and an inability to perform normal daily activities. Other symptoms reported may include weight loss, loss of appetite (anorexia), depression, night sweats, sleep disturbance, general ill feeling (malaise), and low-grade fever. The individual also may report having pain on the sides of the head, especially when chewing (temporal arteritis). The physician will obtain a history of recent and prior illness, including bacterial or virus infection and any signs or symptoms suggestive of temporal arteritis.

Physical exam: The individual may look fatigued. The hip, shoulder, and neck joints and the affected muscles may be tender to the touch (palpation) with decreased range of motion in the proximal hip/leg or shoulder/arm. Swelling may be present in the knees, wrists, and possibly the joints of the hand. Fever may be present.

Tests: A variety of blood tests may be performed, including an erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess the inflammation level; an elevated ESR and CRP are highly characteristic of polymyalgia rheumatica. A complete blood count (CBC) is performed; the white blood cell count (WBC) is usually elevated; a WBC differential will be done to determine types of white blood cells present and red blood count (RBC) and hemoglobin may reveal anemia. Other blood tests may evaluate liver and thyroid function. Tissue typing may be done to determine if HLA-DR4 is positive. Elevation of the cytokines interleukin-2 and interleukin-6 is an extremely sensitive indicator of the condition but tests for cytokines are not routinely performed. Muscle biopsy, as well as negative findings for rheumatoid factor (RF), further define the diagnosis and differentiate the condition. Plain x-rays are not performed because they only rarely show abnormalities in affected joints. MRI is also not necessary for diagnosis but may reveal shoulder joint tenosynovitis. Ultrasound imaging usually agrees with MRI findings. Synovial fluid may be analyzed. If symptoms suggest arteritis, a temporal artery biopsy may be done, but this is not indicated for individuals with mild to moderate polymyalgia.

Source: Medical Disability Advisor



Treatment

Polymyalgia rheumatica is managed but is not cured. Treatment aims to relieve pain and stiffness and resolve other aspects of the condition. Initial treatment usually consists of a low to moderate dose of an oral corticosteroid. Symptoms often resolve within 2 to 3 days, after which the dose is tapered to a low maintenance dose. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used in conjunction with the maintenance dose of corticosteroid. Corticosteroid therapy may need to be maintained for two or more years. Most individuals respond well to corticosteroid therapy. Calcium and vitamin D usually are supplemented in individuals receiving long-term corticosteroid therapy.
Alendronate may be prescribed concurrently with corticosteroid treatment to prevent corticosteroid-induced bone mass loss (osteoporosis). Intramuscular or intravenous corticosteroids may also be administered by injection.

Immunosuppressive drugs such as methotrexate or azathioprine are given to some individuals to allow reduction of dosage and duration of corticosteroid treatment.

Source: Medical Disability Advisor



Prognosis

Polymyalgia rheumatica can cause substantial disability, but with early diagnosis and treatment, its prognosis is excellent. The course of the illness is self-limiting; remission is common within 1 to 3 years, although the course can run 5 or more years. In most cases, corticosteroid treatment produces a dramatic improvement of symptoms within 2 to 3 days. Symptoms recur in half the patients after drug treatment is tapered, and dosage adjustment may be required. The relapse rate at 1 year after drug treatment has been discontinued may run as high as 25% (Epperly). Long-term results of immunosuppressive drugs such as methotrexate show effective relief of pain, swelling, and immobility in most individuals, but physicians generally do not report an advantage of this treatment over corticosteroid therapy.

Source: Medical Disability Advisor



Rehabilitation

Individuals with polymyalgia rheumatica may benefit from a general stretching, strengthening, and aerobic fitness program, in conjunction with pharmacological management (Frearson; Li; Weyland). Because this is a chronic condition, the focus of rehabilitation is to reduce symptoms, preserve function, and prevent loss of motion and strength through exercise. Rehabilitation should begin as a supervised therapy program to ensure that the individual receives adequate instruction and then should progress to an independent program that continues well beyond the conclusion of therapy.

A combination of active and passive treatments, administered simultaneously, may relieve many of the symptoms. Thermal modalities may be used for pain relief and to enable the individual to exercise more comfortably (Braddom). Instruction in relaxation techniques and deep breathing in conjunction with exercise may also be beneficial. The therapist should carefully explain all treatments so that the individual can continue them independently as part of a home program.

The therapist develops both an active stretching and gentle strengthening program that the individual can perform on a routine basis. Individuals learn to stretch any area of tightness and perform strengthening exercises of all joints of the trunk and limbs. In addition, therapy encourages weight-bearing exercises to reduce the risk of osteoporosis that may be caused by prolonged steroid use, a common treatment for this diagnosis (Li). When available, an aquatic exercise program may be incorporated.

Because this is a chronic condition, the therapist must stress to the individual the importance of continuing both pain control techniques and an exercise program after discharge from therapy. Accordingly, prior to discharge, the therapist and the individual should have developed a realistic and comprehensive program of walking, aquatic exercise, stretching, and strengthening exercises.

Occupational therapy may be necessary to address activities of daily living. A home assessment might be indicated to ascertain that the environment is optimal for the individual's needs and to suggest assistive devices that may help with common daily tasks. An ergonomic evaluation may help modify the workstation to enable the individual with polymyalgia rheumatica to maintain his or her employment status.

Because individuals may experience depression if their activities become restricted as a result of exacerbations of this disease, counseling or support group might be needed.

Additional information may provide insight into the rehabilitation needs of these individuals (Oh).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistPolymyalgia Rheumatica
Physical or Occupational TherapistUp to 24 visits within 12 weeks
Note on Nonsurgical Guidelines: It is quite difficult to pinpoint the rehabilitation needs of individuals with polymyalgia rheumatica. Some contributing factors include the point of diagnosis, number of involved joints, acuteness of illness, recurrence, response to medication, joint integrity, anatomical involvement and progression of disease.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Serious complications are not typical with polymyalgia rheumatica. Temporal arteritis (also called giant cell arteritis) occurs in about 15% of the individuals with polymyalgia rheumatica (Saad). Pain may inhibit the use of muscles, which can lead to muscle wasting (atrophy) in an advanced stage of the condition. Some individuals may be at risk of long-term complications of corticosteroid therapy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations vary, depending on the severity of the symptoms and the effectiveness of treatment. No accommodations should be necessary for individuals who are being effectively treated. Individuals whose treatment is ineffective may experience sleep deprivation, which could affect motor skills and thought processes. Pain, stiffness, and sleep deprivation also could affect the individual's ability to operate machinery, perform tasks that require a great deal of concentration or fine motor skills, and drive a motor vehicle. Pain and stiffness worsen with inactivity, so the individual needs to be able to walk around and stretch on a regular basis. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

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 complain of pain and stiffness in the thighs, hips, upper arms, shoulders, upper torso, and neck that began abruptly or developed over a long period?
  • Did physical exam reveal joint swelling and/or associated fever?
  • Were characteristic findings of elevated ESR and C-reactive protein noted?
  • Were other conditions with similar symptoms considered in the differential diagnosis (e.g., fibromyalgia, cervical spondylosis, rheumatoid arthritis, multiple myeloma, lymphoma, leukemia, osteomyelitis, Parkinsonism, miliary tuberculosis, endocarditis, dermatomyositis, polymyositis, neoplastic disease, and hypothyroidism)?
  • Were symptoms of temporal arteritis present?
  • Were constitutional symptoms such as fever, weight loss, fatigue, or general malaise present?

Regarding treatment:

  • Were symptoms relieved with conservative treatment such as oral corticosteroids and analgesics?
  • Were corticosteroid injections needed for additional relief?
  • Has initial corticosteroid therapy been reduced to a maintenance dose?
  • Does individual take NSAIDs or other analgesics for pain relief?
  • Were immunosuppressive drugs prescribed?
  • Is individual taking calcium and vitamin D supplements while receiving corticosteroid therapy?

Regarding prognosis:

  • Has individual complied with treatment plans and received adequate follow-up care to prevent relapses or flare-ups and complications of corticosteroid therapy?
  • Did individual have physical therapy? Does individual have a home exercise program?
  • Is individual compliant with rehabilitation regimen?
  • If necessary, is individual active in counseling or a support group?
  • Has individual's employer made appropriate accommodations to allow a safe return to work?
  • Did individual experience any associated conditions or complications, such as muscle wasting or temporal arteritis that could affect recovery and prognosis?
  • Does individual have an existing condition, such as rheumatoid arthritis, depression, obesity, or spine deformities that could affect recovery and prognosis?

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Epperly, Ted, Kevin Moore, and James Harrover. "Polymyalgia Rheumatica and Temporal Arteritis." American Academy of Family Physicians. 15 Aug. 2004. 6 Mar. 2009 <http://www.aafp.org/afp/20000815/789.html>.

Frearson, R., T. Cassidy, and J. Newton. "Polymyalgia Rheumatica and Temporal Arteritis: Evidence and Guidelines for Diagnosis and Management in Older People." Age Ageing 32 4 (2003): 370-374. National Center for Biotechnology Information. National Library of Medicine. 24 Oct. 2008 <PMID: 12851178>.

Li, C., and B. Dasgupta. "Corticosteroids in Polymyalgia Rheumatica--A Review of Different Treatment Schedules." Clinical and Experimental Rheumatology 18 4 Suppl 20 (2000): S56-S57. National Center for Biotechnology Information. National Library of Medicine. 24 Oct. 2009 <PMID: 10948765>.

Nochimson, Geofrey. "Polymyalgia Rheumatica." eMedicine. Eds. Michael S. Beeson, et al. 24 Sep. 2008. Medscape. 6 Mar. 2009 <http://emedicine.medscape.com/article/808755-overview>.

Oh, T. H., et al. "Rehabilitation of Orthopedic and Rheumatologic Disorders. 2. Connective Tissue Disease." Archives of Physical and Medical Rehabilitation 81 2 Suppl 1 (2000): S60-S66. National Center for Biotechnology Information. National Library of Medicine. 24 Dec. 2009 <PMID: 10721762>.

Saad, Ehab R., et al. "Polymyalgia Rheumatica." eMedicine. Eds. Kristine M. Lohr, et al. 26 Nov. 2007. Medscape. 6 Mar. 2009 <http://emedicine.medscape.com/article/330815-overview>.

Weyland, C. M., and J. J. Goronzy. "Giant-Cell Arteritis and Polymyalgia Rheumatica." Annals of Internal Medicine 139 6 (2003): 505-515. National Center for Biotechnology Information. National Library of Medicine. 24 Oct. 2008 <PMID: 13679329>.

Source: Medical Disability Advisor






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