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.

Post-concussion Syndrome

post-concussion syndrome in 한국어 (대한민국)

Related Terms

  • Closed Head Injury Syndrome
  • Mild Brain Injury
  • Postconcussional disorder (PCD)
  • Postconcussional/Postconcussive Syndrome

Differential Diagnosis

Specialists

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

Comorbid Conditions

  • Depressive disorders
  • Post-traumatic cognitive impairment
  • Post-traumatic headache
  • Post-traumatic seizures
  • Post-traumatic stress disorder
  • Substance abuse

Factors Influencing Duration

The length of disability is highly variable and dependent upon the nature of the head trauma and associated symptoms. Factors influencing the length of disability include the individual's response to medications and psychotherapy; the presence of substance abuse or other psychiatric disorders; the individual's access to a supportive emotional network; and any secondary gain, such as financial gain related to litigation, increased attention from friends and family, and avoidance of work or other responsibilities. Some orthopedic and neurological complications may be present, depending upon the severity and circumstances of the trauma.

Medical Codes

ICD-9-CM:
310.2 - Postconcussion Syndrome

Overview

Post-concussion syndrome, first described by Strauss and Savitsky in 1934, is characterized by impairments in memory, attention, and concentration (cognition); emotional state (affect); and behavior following a closed head injury. In a closed head injury, there is no penetration of the skull, but trauma results in the brain knocking against the hard inner surface of the skull. The closed head injury itself may be accompanied by loss of consciousness, loss of memory of the trauma and events immediately following (post-traumatic amnesia), and possibly post-traumatic seizure disorder. Post-concussion syndrome usually follows mild head injury, in which loss or alteration in consciousness lasts less than 20 minutes. Cognitive symptoms include poor concentration, attention deficits, and impaired memory. Affective symptoms may include irritability, anxiety, depression, or fluctuation in mood (emotional lability). Other symptoms can include fatigue, headaches, vertigo, or an intolerance of noise (phonophobia) and bright lights (photophobia). Occasionally, there will be visual or hearing impairments or a loss of the sense of smell (anosmia), which may affect appetite.

Incidence and Prevalence: Most cases of traumatic brain injury (TBI) are not severe enough to require hospitalization, and thus the prevalence and incidence of this injury is underreported. There are no current databases that follow the incidence of mild concussion, but the Centers for Disease Control and Prevention (CDC) estimates that about 75% of TBIs are concussions or other forms of mild TBI (Summers; CDC). Each year an estimated 1.7 million Americans sustain a TBI; about 1,365,000 are treated in emergency rooms, 275,000 are hospitalized, and about 52,000 of them die (CDC; Faul).

Up to 80% of those with mild to moderate brain injury will experience some symptoms of post-concussion syndrome (Evans).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Women are more likely than men to develop post-concussion syndrome. Increasing age is a risk factor for post-concussion syndrome (Mayo Clinic).

Source: Medical Disability Advisor



Diagnosis

History: Al least three of the following symptoms occur after a trauma sufficiently severe to result in loss of consciousness; the symptoms last at least 3 months: headache, vertigo or dizziness, fatigue, insomnia, anger that occurs without a good reason, anxiety, depression or mood swings, and personality changes such as inappropriate behavior, apathy, or lack of spontaneity. The individual may have trouble paying attention, concentrating, changing focus from one activity to another, performing more than one mental activity at the same time, remembering information, and learning new information. The impairment represents a significant decline from pre-trauma functioning and causes significant difficulty with school or workplace performance. Post-concussion syndrome is not considered to be the diagnosis if the individual has dementia following trauma to the head.

Physical exam: Physical impairments that may be observed include loss of sense of smell (anosmia), slowed movement or speech (psychomotor retardation), impaired gait on specialized tests such as standing with feet together and eyes closed (Romberg test) or walking a straight line (tandem gait), or other subtle neurological findings. A general physical and neurological examination will exclude other disorders as a cause of the symptoms.

Tests: Skull x-rays, brain computed tomography (CT) scan or magnetic resonance imaging (MRI), and psychological tests may all be performed.

Neuropsychological testing has limited use in most individuals with post-concussion symptoms. Among those with post-concussion syndrome, those with prominent cognitive or psychological complaints are best suited for successful testing. Successful testing is administered by well-trained experienced clinicians and must be specifically tailored to the needs of the patient. (Lezak). The reader may also wish to review recommendations for testing from the AMA Guides 6th edition.

These tests can sometimes be utilized to determine not only premorbid level of functioning according to age group, but also current deficits so that appropriate treatment plans can be developed to help the individual regain different levels of cognitive functioning. Electroencephalogram (EEG) may be indicated if seizures are suspected.

Source: Medical Disability Advisor



Treatment

Treatment options vary according to the nature of the trauma and associated symptoms. Medication therapy may be helpful for specific areas of concern such as sleep disturbances, depression, anxiety, headaches, or seizures. Psychotherapy, specifically the behavioral approaches, is helpful, depending upon the individual's level of cognitive impairment. Substance abuse treatment may also be indicated.

Typically, family counseling is also important to help family members adjust to changes and to educate the family on how to support the individual in facilitating a gradual return to everyday activities.

Source: Medical Disability Advisor



Prognosis

In most cases of mild to moderate head injury, the symptoms clear up in 6 to 12 months. However, some individuals may experience symptoms for several years and may never return to normal. Residual impairment and changes in mood (excitement or depression) are common. Depending on the severity of the injury, there may be residual cognitive impairment or seizures.

Source: Medical Disability Advisor



Rehabilitation

In addition to psychotherapy and pharmacotherapy treatments, occupational therapy may be helpful. Occupational therapy may help the individual develop communication skills, identify and match personal skills and work habits to the workplace, and learn how participation in leisure activities contributes to overall health and well being. In the first weeks or months after the head trauma, physical therapy may be useful to improve balance, coordination, and vestibular responses that may have been affected by the injury. Cognitive rehabilitation may help the individual cope with memory or concentration problems through strategies such as making lists or learning new information presented in writing as well as verbally.

The treatment team is comprised of the physiatrist, physical therapist, occupational therapist, psychologist specializing in rehabilitation/neuropsychology, and in-home care assistance if needed when the individual initially returns home.

Source: Medical Disability Advisor



Complications

Complications may be caused by psychosocial factors. Substance abuse and major depression may occur and require treatment in their own right. Impairments in memory, vision, hearing, and sense of smell that may have resulted from the head trauma can also complicate recovery. Seizures (post-traumatic epilepsy), persistent headaches (post-traumatic headache), or specific neurological impairments may also occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Accommodations may include modifying the work space to decrease noise and visual distractions; introducing the individual to new or stressful situations gradually under appropriate supervision and support; providing written instructions and new information in small steps; allowing break time according to individual needs rather than a fixed schedule; limiting physical tasks that involve stooping, physical exertion, noise, and that cause sneezing and excitement; adjusting or eliminating highly stressful activities; providing sensitivity training for coworkers; and providing praise and positive reinforcement. Individuals with seizures should not work at heights, drive, or operate heavy machinery. Persistent memory problems may require reassignment of job duties or even result in total disability. Avoiding work environments with loud noise or bright lights may help decrease headaches.

For more information refer to "Work Ability and Return to Work," pages 326–328.

Risk: Individuals with post-concussion syndrome are not at risk of harm when performing work activities for which they have appropriate intellect and motor skills. Following physician clearance for return to work after head injury, the brain does not get worse with activity. Other than necessary accommodations, there is no basis for work restrictions unless post-traumatic seizures are present.

Capacity: Capacity may be affected in individuals with post-concussion syndrome following severe brain injury due to impairment in intellectual or motor skills needed to perform essential work functions. Functional testing or a trial of supervised work activity may be helpful in determining work ability. Contact physician for details.

Tolerance: Tolerance is expressed according to the individual's complaints of headache, fatigue, and the inability to concentrate, which may be mitigated by temporary modification of work tasks. Personality changes following severe TBI may become significant obstacles to return to work because of changes in motivation and effort.

Source: Medical Disability Advisor



Maximum Medical Improvement

30 to 360 days (wide range reflecting severity of initial mechanism of injury).

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 post-concussion syndrome been confirmed?
  • Is there evidence of neurological problems following head trauma, such as seizures or memory problems?
  • Have well-defined neurological, metabolic, or anatomic abnormalities been ruled out?
  • Is additional testing warranted?
  • Does the individual have a coexisting medical or psychological condition that may affect recovery?
  • Have changes in physical and cognitive functioning resulted in a depressive disorder?

Regarding treatment:

  • Has drug therapy been effective for specific areas of concern, such as sleep disturbances, depression, anxiety, headaches, or seizures?
  • Is individual taking medication as prescribed? Are side effects interfering with use or benefit from that particular medication? Are too many medications, excessive doses, or substance abuse resulting in cognitive impairment?
  • Could other medication options be used instead?
  • Are post-traumatic headaches and/or post-traumatic seizures being properly addressed?
  • Depending on the level of cognitive impairment, would individual benefit from more frequent sessions or a different type of therapy?
  • Because coexisting substance abuse may complicate treatment and delay recovery, would individual benefit from enrollment in a substance abuse treatment program?
  • Is individual receiving psychotherapy? Physical and/or occupational therapy?

Regarding prognosis:

  • Do symptoms persist despite treatment?
  • Does cognitive impairment persist?
  • Would cognitive or vocational rehabilitation be beneficial?
  • Would individual benefit from additional psychotherapy or enrollment in a support group?
  • Are other factors prolonging disability, such as financial gain related to litigation, or secondary gain related to increased attention from family and friends?
  • Did the individual have a pre-existing psychological disorder prior to the injury? If so, what was the diagnosis?
  • What type of treatment was provided?
  • How did the individual respond to past psychological treatment?

Source: Medical Disability Advisor



References

Cited

"Get the Stats on Traumatic Brain Injury." CDC. Centers for Disease Control and Prevention. 1 Nov. 2014 <http://www.cdc.gov/traumaticbraininjury/pdf/Bluebook_factsheet-a.pdf>.

Faul, Mark. "Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006." CDC. Centers for Disease Control and Prevention. 1 Nov. 2014 <http://www.cdc.gov/traumaticbraininjury/pdf/tbi_blue_book_externalcause.pdf>.

Legome, Eric L. "Postconcussive Syndrome." eMedicine. Eds. Trevor John Mills, et al. 16 Oct. 2014. Medscape. 1 Nov. 2014 <http://emedicine.medscape.com/article/828904-overview>.

Lezak, Muriel Deutsch. Neuropsychological Assessment. Oxford University Press, 2004.

Mayo Clinic Staff. "Post-Concussion Syndrome." MayoClinic.com. Mayo Foundation for Medical Education and Research. 1 Nov. 2014 <http://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/basics/definition/con-20032705>.

Summers, C. R., B. Ivins, and K. A. Schwab. "Traumatic Brain Injury in the United States: An Epidemiologic Overview." Mount Sinai Journal of Medicine 76 (2009): 105-110.

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.

Source: Medical Disability Advisor






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