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.

Raynaud Phenomenon


Related Terms

  • Paroxysmal Digital Cyanosis Syndrome
  • Raynaud's Syndrome (Secondary Raynaud’s Phenomenon)
  • Raynaud’s Disease (Primary Raynaud’s Phenomenon)
  • Vascular Insufficiency
  • Vibration White-finger

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Internal Medicine Physician
  • Neurologist
  • Rheumatologist
  • Vascular Surgeon

Comorbid Conditions

  • Any condition that reduces flow of oxygen-rich blood to the extremities
  • Cardiopulmonary conditions
  • Inflammatory conditions
  • Nervous system disorders

Factors Influencing Duration

Duration is influenced by the severity of symptoms, response to treatment, and complications.

Medical Codes

ICD-9-CM:
443.0 - Raynauds Syndrome, Disease, Phenomenon (Secondary)

Overview

Raynaud phenomenon is an excessive reduction in blood flow in response to cold or emotional stress that can cause discoloration (pallor, cyanosis, erythema) of the fingers and toes. Raynaud phenomenon itself is just a sign of decreased blood flow (hypoperfusion) accompanied by a symptom (pain or discomfort). Raynaud phenomenon may be primary or secondary.

In primary Raynaud phenomenon (> 80% of cases), the exact cause of the reduction of blood flow is unknown (idiopathic). This is called Raynaud disease, and it is thought to be associated with increased nervous system stimulation in the blood vessel walls.

Secondary Raynaud phenomenon (Raynaud syndrome) (20% of cases) is a syndrome where the blood flow reduction is caused by a specific known primary disease, most commonly autoimmune or connective tissue disorders. It is almost always present, for example, as a symptom in scleroderma, a connective tissue disease that involves vascular system abnormalities. Because it is associated with other connective tissue diseases as well, especially those with inflammation such as systemic lupus erythematosus (SLE), rheumatoid arthritis, and vasculitis, vasoconstriction may be the result of an antigen-antibody immune response.

Upon exposure to cold or in times of emotional stress, the small blood vessels (arterioles) supplying fingers and toes can suddenly contract (vasoconstriction) and go into spasm. The fingers, usually on both hands, are affected more often than the toes. The thumb is not usually involved. The condition can progress to shrinkage of the affected digits and the formation of ulcers that damage tissue, resulting in open wounds that can become chronic infections under the fingernails and toenails.

Raynaud phenomenon is a recognized occupational disorder that develops in individuals who use vibrating hand tools and machinery such as pneumatic drills and chain saws (vibration white finger [VWF]), individuals whose work involves repeated finger trauma such as typing and playing the piano, and individuals who work in cold environments such as meat processing plants. Arterial diseases such as Buerger's disease (which occurs most often in smokers), atherosclerosis, embolism, and thrombosis may lead to Raynaud phenomenon. Certain drugs that affect the blood vessels (such as calcium channel blockers, beta-blockers, vasoconstrictors, and nicotine from cigarette smoking or chewing tobacco) are also known to produce similar symptoms and may be associated with the phenomenon. The disorder has been known to occur secondary to frostbite, leading to a theory that the vessel walls may be intrinsically hyperreactive to cold. Raynaud phenomenon has also been linked to migraine headaches, spasms in the coronary arteries (Prinzmetal's angina), and other conditions involving constriction of blood vessels.

Incidence and Prevalence: In the general population, Raynaud phenomenon may affect from 5% to 15% of individuals (Goldman). Raynaud phenomenon occurs more often in females (3 to 12.5% of men and 6 to 20% of women) ("Questions"). It usually develops before age 20 (Goldman). Men generally develop the condition somewhat later than women.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals who smoke or use chewing tobacco are at increased risk for Raynaud phenomenon, due to the vasoconstrictive effects of nicotine. Caffeine also worsens the attacks. There is a hormonal component, and possibly also a hereditary component to the disorder. Sufferers are more likely to have migraine and angina than controls.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report that, upon exposure to cold or in times of stress, their fingers or toes turn white, cold, become bluish in color (cyanosis) and then, with heat or warmth, become red; afterwards, color returns to normal. Burning pain, as well as tingling and/or numbness (paresthesias) may occur in the affected fingers or toes. Symptoms usually begin at the tips of the fingers and toes and gradually spread to involve more of the digits; the symptoms may be bilateral. Episodes may last from minutes to hours, but are not generally severe enough to result in tissue loss from lack of circulation. Diagnosis is based in part on the individual's history, including the recurrence of symptoms for at least 2 years.

Physical exam: Severe or chronic cases may display shiny, tight skin, with ulcers on the fingertips. Tissue death (gangrene) is present only in the most severe cases. Physical manifestations are usually sufficient for diagnosis.

Tests: Full blood count may reveal a normocytic anemia suggesting the anemia of chronic disease or renal failure. Doppler ultrasound may help to assess blood flow. Digital artery pressures in the arteries of the fingers before and after the hands have been cooled may show a decrease of at least 15 mmHg, which is diagnostic. Blood tests for urea and electrolytes can suggest renal impairment. Thyroid function tests may reveal hypothyroidism. Response of the peripheral circulation to cold can be tested by comparing readings from multiple blood pressure cuffs (plethysmography) placed in different locations on arms and legs. Autoantibody screening, tests for rheumatoid factor, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may suggest specific causative illnesses or a generalized inflammatory process. If antinuclear antibody tests are negative for antinuclear antibody titer, the condition will probably be labeled as primary Raynaud phenomenon.

Source: Medical Disability Advisor



Treatment

Symptoms are generally relieved by warmth. Besides protecting the body, especially the hands and feet, from cold, Raynaud syndrome (secondary Raynaud phenomenon) is managed primarily by treating the underlying cause (disease or condition) when one can be identified. For both secondary and primary Raynaud phenomenon, avoiding triggers such as cold, keeping a warm core body temperature, reducing emotional stress, and avoiding cigarette smoking (including passive smoking) or chewing tobacco can help. When symptoms are unusually severe, vasodilators that relax the walls of blood vessels such as calcium channel blockers (e.g., nifedipine) or prazosin may be prescribed as treatment.

Drugs that alter circulation through vasodilation or vasoconstriction (sympathomimetic drugs) may need to be changed or discontinued. The use of vibrating machinery or tools may need to be discontinued or minimized.

If ulcers develop in spite of other treatments, nerves controlling the contraction response may be excised (sympathectomy) in an effort to improve blood flow to the skin.

Source: Medical Disability Advisor



Prognosis

The prognosis for Raynaud disease (primary Raynaud phenomenon) is fair, provided the individual complies with instructions about keeping warm and avoiding aggravating factors such as prolonged vibration, repetitive finger motion, tobacco, and certain antihypertensive drugs (beta-blockers) that are known to cause symptom exacerbation. Few cases become severe enough to require radical treatment for ulceration or amputation for gangrene.

The prognosis for Raynaud syndrome (secondary Raynaud phenomenon) is dependent on the ability to treat the underlying conditions. Some of these conditions are progressive and therefore the prognosis can be guarded.

Source: Medical Disability Advisor



Rehabilitation

Please refer to the frequency of visits below.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistRaynaud Phenomenon
Physical or Occupational TherapistUp to 3 visits for home exercise program
Surgical
SpecialistRaynaud Phenomenon
Physical or Occupational TherapistDepends on underlying disease

Source: Medical Disability Advisor



Complications

The walls of the small arteries supplying the fingers and toes may gradually thicken and permanently reduce blood flow, which may lead to painful ulcerations or tissue death (gangrene) at the tips of the affected digits. In rare cases, gangrenous digits may require amputation.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations may include monitoring the temperature of indoor/outdoor work areas and avoiding or minimizing the use of vibrating tools and machinery. Protective measures should be taken such as wearing warm clothing, using coated tool handles, and using anti-vibration gloves.

Risk: Risk is dependent on the cause of the decreased blood flow.

Capacity: Capacity is determined by the location and severity of decreased blood flow.

Tolerance: Tolerance is affected by pain which is impacted by the capacity; this is determined by the location and severity of decreased blood flow to the affected digits.

Accommodations: Employers able to accommodate physical demands are more likely to have employees return to work sooner.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI for Raynaud syndrome or phenomenon is dependent on the disease that is causing the phenomenon. Review the specific disease for details. MMI for Raynaud disease is undetermined. Proper management may result in a stable condition by 60 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:

  • Has diagnosis of Raynaud phenomenon been confirmed? Is it primary or secondary?
  • Have other causes for the poor circulation to the extremities been ruled out?
  • Has the underlying condition causing secondary Raynaud phenomenon been identified?
  • Has individual experienced any complications related to the Raynaud phenomenon such as shiny, tight skin, with ulcers on the fingertips?
  • Does individual use tobacco? Caffeine?
  • Is individual taking beta blockers?

Regarding treatment:

  • If the underlying condition causing secondary Raynaud phenomenon has been identified, is it being effectively treated?
  • Have vasodilators that relax the walls of blood vessels such as calcium channel blockers (e.g., nifedipine) or prazosin been prescribed?
  • Does individual's occupation require the use of vibrating machinery or tools?
  • Is individual abstaining from the use of tobacco? Caffeine?
  • Is individual utilizing adequate protection from cold temperatures?
  • Would individual benefit from a stress management program?

Regarding prognosis:

  • Do work accommodations include monitoring the temperature of indoor/outdoor work areas and the wearing of warm, protective clothing? Reduction in repetitive finger motion?
  • Can the use of vibrating tools and machinery be avoided or minimized through the use of coated tool handles and anti-vibration gloves?
  • Would individual benefit from enrollment in a community smoking cessation program?

Source: Medical Disability Advisor



References

Cited

"Questions and Answers about Raynaud’s Phenomenon." NIH. Aug. 2013. National Center for Biotechnology Information. 22 Dec. 2014 <http://www.niams.nih.gov/health_info/Raynauds_Phenomenon/default.asp>.

Goldman, Lee, and J. Claude Bennett, eds. "Raynaud's Phenomena." Cecil Textbook of Medicine. 21st ed. Philadelphia: W.B. Saunders, 2000. 1520-1521.

Source: Medical Disability Advisor






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