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.

Rotator Cuff Syndrome


Related Terms

  • Adhesive Capsulitis
  • Impingement Syndrome
  • Painful Arc Syndrome
  • Rotator Cuff Tear
  • Rotator Cuff Tendonitis
  • Supraspinatus Syndrome

Differential Diagnosis

Specialists

  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

Factors that may influence disability include the individual’s age, occupation, and overall health, the severity of symptoms, whether one or both shoulders are affected, whether the dominant or nondominant arm is involved, whether the individual must perform overhead work, and whether the individual can be assigned a job where full mobility of one shoulder is not needed.

Medical Codes

ICD-9-CM:
726.1 - Rotator Cuff Syndrome of Shoulder and Allied Disorders
726.10 - Disorders of Bursae and Tendons in Shoulder Region, Unspecified; Rotator Cuff Syndrome NOS; Supraspinatus Syndrome NOS
726.11 - Calcifying Tendinitis of Shoulder
726.19 - Other Specified Disorders of Rotator Cuff Syndrome of Shoulder and Allied Disorders

Overview

© Reed Group
The shoulder is the most mobile of all the joints in the body. To attain this level of mobility, the shoulder must sacrifice stability, in the form of less ligamentous attachments and bony stability. The shoulder, therefore, is primarily stabilized by the rotator cuff muscles. The rotator cuff comprises four muscles — the subscapularis, the supraspinatus, the infraspinatus and the teres minor — and their musculotendinous attachments. The tendons that are linked to these four muscles attach to the humerus and fuse together to form the rotator cuff.

If the rotator complex weakens in any capacity (be it from injury, deconditioning, aging, etc), the less able the muscles will be to pull the arm firmly into the shoulder socket or joint. Therefore as the joint becomes less stable, the humeral head can move around in the joint more easily. With increasing instability, several dysfunctions and concomitant symptoms can arise (pain in the shoulder). Almost always, the first dysfunction or symptom to arise is pain. When the muscles are weak, the rotator cuff can no longer handle the load of raising (abduction) and flexing the arm. Examples of the movements that elicit pain include putting on a seatbelt; washing one's hair; reaching for a glass in the cupboard; rolling over onto the shoulder in bed; reaching to switch on a light, and driving (turning or steering) with the affected arm.

The pain is also felt in a very distinct area, one that is classic for rotator cuff syndrome — the front of the shoulder. This may be similar to the presentation for other shoulder conditions such as impingement, frozen shoulder, rotator cuff tear biceps tendon tear and/or osteoarthritis.

There is some overlap with this diagnosis and the other conditions listed above. Some authors believe that rotator cuff syndrome reflects instability in the shoulder due to muscle imbalance or weakness and that rotator cuff tear is the final common pathway (Ramsey).

Repetitive motion along with individual variations in the anatomy of the shoulder and trauma can lead to rotator cuff injuries. Rotator cuff syndrome is a disorder most frequently diagnosed in those whose work involves repeated or sustained raising of the upper arms more than 30° over horizontal. Such repetitive motion may irritate the muscles and tendons by putting pressure against the bone at the top of the shoulder blade. When the arm is raised repeatedly, front edge of the shoulder blade (acromion) can rub across the rotator cuff (impingement syndrome or painful arc syndrome). If rotator cuff injuries are diagnosed early, causes can be identified and effective treatments implemented, thereby preventing further injury or deterioration.

Rotator cuff impingement syndrome is divided into three stages of severity. In stage I, swelling (edema) and/or bleeding (hemorrhage) occurs. Stage I is frequently associated with an overuse injury. At this stage, the syndrome can either be reversed or it can progress. In stage II, there is inflammation of the tendon (tendinitis) and development of scar tissue (fibrosis). Stage III frequently involves a tendon rupture or muscle tear and often represents years of fibrosis and tendinitis.

Incidence and Prevalence: Shoulder pain is the third most common musculoskeletal disorder; estimates of all shoulder disorders are 10 per 1,000 population, with a peak incidence of 25 per 1,000 population aged 42 to 46 years. Among those age 60 years or older, 21% were found to have shoulder syndromes, most of which were attributable to the rotator cuff (Roy). Nevertheless, the actual incidence of rotator cuff syndrome is uncertain since about 34% of the population may have a torn rotator cuff but no pain (Roy).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for rotator-cuff related disorders are not well defined. There are no large prospective cohort studies that include physical examinations and detailed job-related physical exposure measurements to compare, contrast, or quantify purported job-related physical factor risks (Hegmann).

The prevalence varies depending on the inclusion criteria. Studies suggest excessive cumulative daily loads contribute to work-related shoulder conditions and that shoulder-arm pain seems related to psychological factors. For further information, refer to "Disease and Injury Causation," pages 185-190.

Symptoms of rotator cuff syndrome often occur with repeated lifting of heavy weights over the head (e.g., painters, welders, plate workers, and slaughterhouse workers). However, this syndrome also has been reported in sewing machine operators. It can occur in athletes who engage in sports such as swimming, tennis, weightlifting, and baseball in which the arm is repeatedly raised over the head. Younger individuals are more likely to experience rotator cuff syndrome as a result of trauma, overuse, shoulder (glenohumeral) joint instability, or muscle imbalance. In older individuals, the syndrome is more commonly related to chronic wear and shoulder degeneration. Rotator cuff syndrome is most common in the dominant arm.

Stage I rotator cuff syndrome is found most often in individuals under age 25; stage II occurs most often in individuals between 25 and 40; stage III occurs mainly in individuals over age 50 (Quintana). Men develop rotator cuff syndrome twice as often as women, possibly because of work activities as noted above. The syndrome occurs independently of race, ethnicity, or geographic location.

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history, including the individual's occupation and recreational activities will be taken. A good description of the shoulder pain including the onset, timing, location, radiation, quality of pain, aggravating and alleviation factors, presence of associated symptoms, and association with any activities helps to diagnose rotator cuff syndrome. The key is that the initial pain is felt only in the front of the shoulder. Over time the individual may report aching pain in the shoulder or referred pain along the outside upper arm. The pain often worsens when the arm is lifted overhead and at night. Other symptoms may include weakness and reduced range of motion. The onset of symptoms is often gradual.

Physical exam: Examination of the shoulder begins with a thorough inspection for any deformities, scars, edema, or decrease in muscle bulk (atrophy). Next, the entire shoulder joint and all of its muscle groups are palpated for tenderness. Both active and passive range of motion is determined by rotating the individual's arm through different planes, noting any decrease in range of motion and any pain. The pain may be more intense with certain movements or when pressure is applied; it can disappear with other movements. There may be a grating, clicking or cracking sound (crepitus) in the shoulder. Muscle strength testing and neurological testing should be performed. Special maneuvers during the physical examination (such as the Neer impingement, Hawkins-Kennedy impingement, drop-arm, apprehension, and relocation tests) may be helpful. A thorough exam includes evaluation of the cervical spine along with both arms and shoulders.

Tests: X-rays (anteroposterior view, axillary view, supraspinatus view) are an essential component of evaluation to rule out calcium deposits in the joint, and bone or joint diseases. If symptoms do not improve following 3 to 6 weeks of conservative therapy, other advanced imaging modalities may prove helpful, especially in diagnosing suspected rotator cuff tears. MRI detects a wide spectrum of rotator cuff disease, including degeneration and partial to complete tears. It can also reveal soft tissue abnormalities, and proves especially valuable in tracking postoperative healing. Ultrasonography proves useful in diagnosing moderately large rotator cuff tears and evaluating other cuff disease. Widespread use of arthrography has decreased with the advent of MRI, but it remains useful in individuals for whom MRI is contraindicated (e.g., those with a pacemaker, cerebral aneurysm clip, or recent cardiac stent). Arthrography involves injection of contrast media into the glenohumeral joint followed by plain x-rays. Observed leakage of contrast material into the subacromial or subdeltoid spaces following injection indicates a full-thickness rotator cuff tear. Other diagnostic tests for rotator cuff syndrome are bone scintigraphy and CT scan, often with contrast media (CT-arthrography). Electromyography (EMG) and nerve conduction velocity studies (NCVs) may be helpful if neurologic involvement is suspected.

Source: Medical Disability Advisor



Treatment

During the acute phase of rotator cuff syndrome, conservative treatment consists of rest and activity modification, ice, and the use of (NSAIDs). The goals are to decrease inflammation and pain and restore normal shoulder function. Activities causing the pain should be resumed gradually when pain is gone. Sometimes a cortisone injection into the space above the rotator cuff tendon (subacromial corticosteroid injection) helps relieve swelling and inflammation. Application of ice to the tender area for 15 minutes 3 to 4 times a day also is helpful as is a supervised program of stretching and strengthening exercises to increase range-of-motion. Recovery of function should be stressed. An on-going home exercise program is essential to help prevent recurrence. Surgery may be considered for those individuals who show no improvement after 3 months of aggressive therapy or who continue to be bothered by weakness. The decision to perform surgery would be based on progression of condition from “syndrome” to perhaps impingement, rotator cuff tear, frozen shoulder, etc.

Indications for surgery vary but should take into consideration an individual’s age, type and severity of tear (partial to full-thickness muscle tears), duration of symptoms, and willingness and ability to comply with postoperative therapy. The main goals of surgery are improved strength, increased function, and pain relief. Chronic rotator cuff syndrome with severe impingement may be treated by cutting into the shoulder and repairing the bone and/or tendon and/or the muscle (arthroscopic acromioplasty). Rotator cuff surgery is done to repair a torn rotator cuff. (See Rotator Cuff Repair topic.) Bone spurs or calcium deposits causing impingement may be removed at the same time. Surgery must be followed by physical therapy to improve strength and range-of-motion followed by an on-going home exercise program.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Shoulder Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Recovery often depends on the stage of the syndrome and the age of the individual. Some individuals whose rotator cuff syndrome is caused by repetitive above-the-shoulder lifting may recover completely if the repetitive work is stopped and an aggressive, nonsurgical treatment plan (i.e., ice, strengthening, and range-of-motion exercises) is followed. Success rates with such conservative treatment range from 33% to 90%, with longer recovery times noted in older individuals (Quintana). Surgical outcomes often depend on the willingness and ability of an individual to participate actively in postoperative physical therapy and home exercise. The reported success rate for surgery to treat torn rotator cuffs is between 77% and 95% ("Shoulder Rotator"; Quintana). In many individuals who resume overhead work or other activity that initially caused the problem, recurrent episodes may continue despite appropriate acute treatment. These individuals need to alter their work or recreational activities.

The outcome for impingement syndrome (which may be similar to rotator cuff syndrome) is usually good to excellent dependent on age and job activities (Melhorn) However, durations will be longer if the following factors are identified: awkward posture (hand over shoulder), high forceful effort, high job demand, and limited decision making by patient are predictors of chronic shoulder pain at work (Herin).

Length of disability, like disability durations are dependent on the cause for the rotator cuff syndrome (such as impingement), the treatment provided, and the job activities required. The disability durations are also affected by the age of the patient and their physical condition (capacity) prior to the onset of their rotator cuff syndrome. For further information, refer to "Work Ability and Return to Work,” pages 179-185.

Source: Medical Disability Advisor



Rehabilitation

Rotator cuff syndrome represents a precursor to a shoulder impingement syndrome and possible progression to rotator cuff tear. The early goals of rehabilitation for rotator cuff syndrome are to decrease pain and inflammation and to reduce the stress on the irritated tendon and/or tissues (Morrison, "Shoulder Impingement"; Rubin). In conjunction with pharmacological management, individuals are instructed in the use of cold treatments to the shoulder to decrease inflammation. Reduction of stress to the irritated tissue(s) is often achieved through education, ergonomic adjustments, and/or work modifications aimed at reducing the offending activities, which often include repetitive movements or sustained positions where the elbow is raised above the shoulder level. Posture must also be addressed as thoracic kyphosis can contribute to shoulder impingement.

As with other tendinopathies there are several phases of therapy. After pain and inflammation is controlled and work modifications made, range of motion and strengthening should be addressed. Stiffness may be prevented by passive range of motion exercises conducted during supervised rehabilitation and a home exercise program (Ludewig). Posterior capsule stretching is recommended to restore normal mobility of the glenohumeral joint and help reduce impingement. Strengthening should initially address scapulothoracic stabilizers, then progress to eccentric strengthening of scapulothoracic and rotator cuff muscles (Morrison, "Non-Operative Treatment"; Morrison, "Shoulder Impingement"; Rubin). Proprioception is then emphasized with eventual progression to open chain activities and then task- or sport-specific skills (Bowen).

Some evidence from randomized controlled trials suggests that manual therapy in conjunction with a program of strengthening and stretching is more beneficial than strengthening and stretching alone (Bang). Throughout rehabilitation, exercise intensity and duration should be increased until full functional ability is regained (Rubin).

While many individuals respond well to the conservative management of rotator cuff syndrome, surgical intervention may be required.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistRotator Cuff Syndrome
Physical or Occupational TherapistUp to 8 visits within 8 weeks
Surgical
SpecialistRotator Cuff Syndrome
Physical or Occupational TherapistUp to 16 visits within 8 weeks
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

The main complication of rotator cuff syndrome occurs when rotator cuff tears go undiagnosed. Symptoms will persist until the rotator cuff is repaired surgically. Another complication results from inadequate treatment. If the shoulder is immobilized in a sling, the individual can develop "frozen shoulder" (adhesive capsulitis). Conditions such as a rotator cuff tear or impingement syndrome may also lead to decreased range of motion in the shoulder. An estimated 4% of rotator cuff ruptures result in joint disease (arthropathy) of the shoulder (Quintana). Proper care, whether conservative or surgical, and appropriate follow-up lessen the likelihood of joint disease and other long-term consequences of rotator cuff syndrome.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Aggravating activities need to be avoided or limited until symptoms have improved or been relieved. During early treatment, the individual should limit or not lift, carry, push, or pull heavy objects. Individuals should limit or not use of the arm with the hand above shoulder level activities. These guides rarely become permanent. An ergonomic evaluation of the workplace may be helpful. A change in job duties, sharing or alternating tasks, a reduced work rate, more frequent rest breaks, and limits on the time and frequency of repetitive activities may be reasonable accommodations. Work-site modifications might include forearm rests for individuals who use computer keyboards frequently, headsets for those who answer telephones and modifications to repetitive activities so that they can be done without or limiting raising the arms overhead. For example, using a single step for a short statured individual that can be removed for a taller individual may be a reasonable accommodation. Individual attention and education can encourage recognition and avoidance of aggravating activities, awareness of shoulder mechanics and early signs of rotator cuff syndrome, and use of proper warm-up techniques.

For insight into potential risk factors for shoulder symptoms and possible modification of job duties, please refer to table 12-1 in “Work Ability,” page 181.

Risk: Re-injury is possible, but most individuals are on modified work.

Capacity: Capacity is dependent on age and physical conditioning before onset of symptoms. Young and well-conditioned individuals often return to work activities soon and will less recurrence that older individuals or those not in good physical condition (have less endurance).

For further information on capacity, refer to “Work Ability,” page 180.

Tolerance: Tolerance is the limiting issue for shoulder impingement. Non-surgical treatment will often result in improvement the length of time and can be long and most individuals want a quick fix (Melhorn). The ability to work through the pain is unique to each individual. Education can modify tolerance.

Accommodations: Most individuals will get better with time and therapy. An employer’s willingness to make accommodations allows the individual time to recover. Older individuals may require more time. Tolerance and accommodation determine the final ability to return to work. Modifications to the workplace or modifications to the job task may allow many individual to return to modified work.

Source: Medical Disability Advisor



Maximum Medical Improvement

This topic refers to pain in the rotator cuff. If no specific diagnosis is available, MMI should occur at 4 weeks after therapy and stable function.

If surgery is required, see "Rotator Cuff Repair," and "Rotator Cuff Tear."

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 have symptoms of rotator cuff syndrome, such as aching pain in the shoulder, especially with reaching overhead?
  • Does individual have an occupation that requires lifting heavy weights overhead?
  • Was a good description of the pain obtained?
  • Has individual had adequate testing to establish the diagnosis?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Did individual respond to conservative treatment?
  • Was a cortisone injection administered?
  • Was surgery necessary? Was it successful?

Regarding prognosis:

  • Has individual stopped overhead work, repetitive lifting, and carrying?
  • Has individual actively participated in the physical therapy?
  • Does individual follow a home exercise program?
  • Does individual have any conditions that may affect recovery?
  • Did any complications arise?

Source: Medical Disability Advisor



References

Cited

"Shoulder Rotator Cuff Disease." Orthopaedic Associates. 21 Jan. 2013 <http://www.orthoassociates.com/SP11B2/>.

Bang, M. D., and G. D. Deyle. "Comparison of Supervised Exercise with and without Manual Physical Therapy for Patients with Shoulder Impingement Syndrome." Orthopedic and Sports Physical Therapy 30 3 (2000): 126-137. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 10721508>.

Bowen, Jay E., and Gerald A. Malanga. "Chapter 14 - Rotator Cuff Tendinitis." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Hegmann, K. T. , et al., eds. Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. Third ed. ACOEM, 2011.

Herin, F. , et al. "Predictors of chronic shoulder pain after 5 years in a working population." Pain 153 11 (2012): 2253-2259.

Ludewig, P. M., and J. D. Borstad. "Effects of a Home Exercise Programme on Shoulder Pain and Functional Status in Construction Workers." Occupational and Environmental Medicine 60 11 (2003): 841-849. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 14573714>.

Melhorn, J. M. "Causation Analysis and Workability." 25th Annual Scientific Session. American Academy of Disability Evaluating. . .,

Melhorn, J. M. "Work-related Shoulder Pain: PERT." 18th Annual Scientific Session. Eds. J. M. Melhorn and D. C. Randolph. American Academy of Disability Evaluating. . ., 1-34.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Morrison, D. S., A. D. Frogameni, and P. Woodworth. "Non-Operative Treatment of Subacromial Impingement Syndrome." Journal of Bone and Joint Surgery 79 5 (1997): 732-737. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 9160946>.

Morrison, D. S., B. S. Greenbaum, and A. Einhorn. "Shoulder Impingement." Orthopedic Clinics of North America 31 2 (2000): 285-293. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 10736397>.

Quintana, Eileen C., et al. "Rotator Cuff Injuries." eMedicine. Ed. Rick Kulkarni. 1 May. 2012. Medscape. 21 Jan. 2013 <http://emedicine.medscape.com/article/827841-overview>.

Ramsey, M. L. , C. L. Getz, and B. O. Parsons. "What's New In Shoulder and Elbow Surgery." Journal of Bone and Joint Surgery 89 (2007): 220-230.

Roy, Andre, et al. "Rotator Cuff Disease." eMedicine. Ed. Rene Cailliet. 18 Jan. 2012. Medscape. 21 Jan. 2013 <http://emedicine.medscape.com/article/328253-overview>.

Rubin, B. D., and E. Kitai. "Fundamental Principles of Shoulder Rehabilitation: Conservative to Postoperative Management." Arthroscopy 18 9 Suppl 2 (2002): 29-39. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 12426529>.

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.

General

Mercier, L. R. "Rotator Cuff Syndrome." Ferri's Clinical Advisor 2009. Ed. Fred Ferri. Philadelphia: Mosby, Inc., 2009.

Source: Medical Disability Advisor






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