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.

Seizures

seizures in français (France)

Related Terms

  • Absence Seizures
  • Attacks
  • Convulsions
  • Epilepsy
  • Fits
  • Spells
  • Tonic-clonic Seizures

Differential Diagnosis

Specialists

  • Family Physician
  • Internal Medicine Physician
  • Neurologist
  • Neurosurgeon

Comorbid Conditions

Factors Influencing Duration

Length of disability may be influenced by the individual's response to treatment, frequency of seizures, underlying cause of the seizures, presence of concomitant chronic illness, mental and physical health status, and specific job duties.

Medical Codes

ICD-9-CM:
345.2 - Petit Mal Status, Epileptic Absence Status
345.3 - Grand Mal Status

Overview

A seizure is a symptom of sudden and transient interruption of the brain function secondary to a chaotic disruption of the normal electrochemical process that transmits information from one nerve cell to another (electrical activity). The disruption occurs within the gray matter of the brain cortex and typically produces a brief period of impaired consciousness, unconsciousness, or focal neurological symptoms such as abnormal sensations, focal involuntary movements such as rapid blinking of the eyes, or widespread, intense, paroxysmal, and involuntary alternating contraction and relaxation of voluntary muscles convulsions). Epilepsy is defined as at least two unprovoked (idiopathic, no identifiable cause) seizures that occur more than 24 hours apart. Epileptic seizures are clinical events that occur as a result of abnormal, transient (hypersynchronous) electrical discharges from a group or groups of nerve cells (cortical neurons) in the cerebral cortex of the brain. Nonepileptic seizures, such as psychogenic seizures and organic non-epileptic seizures, are not directly related to abnormal or excessive disrupted electrical activity in the brain (neuronal discharges). Clinical signs of epileptic seizures vary according to the location of the abnormal discharge in the cerebral cortex and the pattern of distribution of the discharge. Because the brain's primary function is the transmission of electrical impulses, seizures are a common expression of neurologic injury and disease.

It is very important to distinguish an epileptic seizure from nonepileptic events such as syncope (fainting),which is of cardiovascular origin, transient ischemic attack (TIA), migraine (confusional migraine, basilar migraine), movement disorders (tics, nonepileptic myoclonus, paroxysmal choreoathetosis), paroxysmal vertigo, transient global amnesia, sleep disorders (e.g., narcolepsy/cataplexy, benign sleep myoclonus), and psychiatric disorders (e.g., dissociative seizures, panic attacks, factitious seizures). Seizures may be caused by underlying medical conditions (organic non-epileptic seizures) such as metabolic disorders (e.g., hyperammonemia, hypoglycemia, hypocalcemia, hyponatremia), cerebrovascular disease (e.g., cerebral infarction, cerebral hemorrhage, venous thrombosis), brain tumor, trauma to the brain, central nervous system infections (e.g., meningitis, encephalitis), genetic disease, autoimmune disease, neurodegenerative disease, heatstroke, withdrawal from long-term use of alcohol, substance abuse, or medications.

The International League Against Epilepsy (ILAE) classifies epileptic seizures as focal (partial)-onset or generalized-onset seizures, based on how the abnormal brain activity begins. Focal-onset seizures involve a focal portion of one side of the brain (cerebral hemisphere), and generalized-onset seizures occur simultaneously in both sides of the brain. Unclassified seizures do not fit precisely into either class.

Focal- onset seizures are further classified as either simple (no loss of consciousness), complex (dyscognitive) focal (impaired consciousness or loss of consciousness) and secondary generalized tonic-clonic seizures (abnormal electrical discharge spreads to involve both cerebral hemispheres). Focal seizures last a few seconds to a few minutes. Seizures may be preceded by an aura, a simple focal seizure with sensory, motor, autonomic, or psychic manifestations that warns the individual of an impending seizure. Auras cannot always be recorded on an electroencephalograph (EEG), which makes diagnosis difficult. Focal seizures can become secondarily generalized, beginning with an aura. If an aura lasts longer than 30 minutes, the seizure is described as a simple focal status epilepticus.

Complex focal seizures usually begin with a cessation in activity (behavioral arrest) followed by staring, repetitive behavior (automatisms) for 60 to 90 seconds, and confusion after the seizure (post-ictal confusion). Typical automatisms include chewing, lip smacking, mumbling, or fumbling with the hands. Complex focal seizures that originate in the frontal lobe of the brain can produce bizarre movements that resemble riding a bicycle or fencing. Individuals may remember the aura but be unaware that they were not responsive for a period after the aura.

Generalized-onset seizures are classified as absence or cognitive seizures (petit mal seizures), tonic seizures, clonic seizures, myoclonic seizures, atonic seizures (drop seizures), and primary generalized tonic-clonic seizures (grand mal seizures). Absence seizures are more common in children and consist of brief (20 seconds) episodes of impaired consciousness with few or no automatisms, no aura, and no post-ictal confusion. Tonic seizures involve sudden extension or flexion of the head, torso, and/or limbs for several seconds and often occur when the individual is feeling drowsy, has just gone to sleep, or upon awakening. Clonic seizures have more rhythmic bilateral jerking of upper and lower extremities, with or without loss of consciousness. Myoclonic seizures are characterized by brief, irregular jerking that lasts less than a second. This type of seizure may occur in clusters within a few minutes. Atonic seizures occur in individuals with underlying neurological abnormalities and often result in falls and injuries due to loss of postural tone. Tonic-clonic seizures, the most recognized type of seizure, are characterized by tonic extension of the extremities followed by clonic rhythmic movements and prolonged post-ictal confusion.

Incidence and Prevalence: The incidence of single seizures without an identifiable cause is 23 to 61 cases per 100,000 persons-years; the incidence of acute symptomatic seizures is 29 to 39 cases per 100,000 population per year (AlEissa). The reported annual incidence of recurrent seizures not associated with fever (nonfebrile) is approximately 100 cases per 100,000 individuals aged 0 to1 year, 40 per 100,000 individuals aged 39 to 40 years, and 140 per 100,000 individuals aged 79 to 80 years. The cumulative incidence of epilepsy in individuals aged 75 years is 3400 per 100,000 men (3.4%) and 2800 per 100,000 women (2.8%) (Ko).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The highest incidence rate of epilepsy occurs in the very young and very old groups. The incidence rate in children younger than 1 year is 100 to 233 per 100,000; in individuals aged 20 to 60 years is 30 to 40 cases per 100,000, and in patients older than 65 years is 100 to 170 cases per 100,000 (AlEissa). Men are at slightly higher risk than women of first seizures occurring in adulthood, but no statistical differences have been found between numbers of men and women experiencing seizures. No studies have reported any racial differences.

Individuals who have had a stroke or who have a family history of seizures are more likely to develop epileptic seizures (AlEissa). Seizures may be associated with birth trauma, head injury, central nervous system infections, brain tumor, stroke, ingestion of toxic substances, or metabolic imbalance. There may be an inherited tendency toward seizures.

Source: Medical Disability Advisor



Diagnosis

History: An accurate description of the events leading up to the seizure should be obtained from the individual and any witnesses. The individual may have no recall of the seizure itself but may be able to describe symptoms of an aura such as distorted, unpleasant perceptions of odor, vision, or time, as well as preservation of consciousness during the seizure, and post-ictal states. The individual and/or observers may report chewing movements or smacking of the lips, numbness or tingling of the limbs or face, rapid blinking of the eyes, and twitching of the muscles. Observers may report that the individual stopped all activity and had a blank stare or lost consciousness completely. This may have been accompanied by body stiffening (tonic posturing) and either arrhythmic or rhythmic jerking of the limbs (tonic or clonic movements), possibly resulting in self-injury or tongue biting. Loss of control of bowels and bladder may also have occurred. The seizure may have been followed by post-ictal confusion, headache, muscle soreness, lethargy, or deep sleep. It is important to obtain a history of prior seizures including precipitating factors, frequency, duration, type of seizure, anticonvulsant medications (past and present) as well as the individual’s complete medical history including current and prior illnesses (e.g., migraine headaches, hypertension, transient ischemic attack [TIA], stroke, sleep disorders, fainting, vertigo), injuries (especially head trauma), treatment for psychiatric or emotional disorders, medication history, history of drug and/or alcohol use and family history of seizures.

Physical exam: A thorough physical examination is conducted to rule out non-neurologic causes of the seizure, as well as signs of neurocutaneous syndromes (e.g., Sturge-Weber syndrome, tuberous sclerosis,). Examination immediately after a seizure may reveal lethargy, sleepiness, confusion, headache, muscle soreness, and weakness on one side of the body that later resolves (Todd's post-ictal paralysis). A careful neurological examination is done to look for focal abnormalities in the brain such as a tumor or a lesion resulting from stroke or cerebral vascular accident (CVA). Physical examination may reveal fever and neck stiffness suggestive of central nervous system (CNS) infection (e.g., meningitis, encephalitis); blood and spinal fluid may be tested to exclude infection.

Tests: History and physical exam may provide clues as to the type of seizure, but confirmation by EEG improves diagnostic accuracy because it can show the location and distribution of abnormal electrical discharges (epileptogenic focus) and help to identify the seizure type. EEG performed with 24 hours of seizure is more sensitive in detecting abnormalities. However, a negative EEG does not rule out the diagnosis of seizure or epilepsy. Various maneuvers (activation procedures) can be used to trigger abnormal electrical discharges on the EEG that would not be seen otherwise such as performing EEG when the individual has been awake for 24 hours or more (sleep-deprived EEG), or during hyperventilation, or while strobe lights are rhythmically flashed before the eyes (photic stimulation). If the EEG is still negative, but clinical seizures are strongly suspected, video EEG monitoring can be done for longer periods by studying the individual for 24 to 72 hours in an epilepsy monitoring unit. A special event monitor placed on the chest and worn for at least 24 to 48 hours during the individual’s daily activities (Holter monitor) can help identify cardiovascular events that may mimic seizures. Ambulatory electroencephalography (AEEG) monitoring is the neurologic counterpart of the Holter monitor and has proven useful for diagnostic and follow-up purposes.

To rule out stroke, brain tumor, cerebral hemorrhage, or other causes of seizures, the brain usually is studied by neuroimaging such as computed tomography (CT) and magnetic resonance imaging (MRI); both may be done since CT alone can miss more subtle brain lesions. Blood chemistries may be done to check for low blood glucose levels (hypoglycemia), electrolyte levels (i.e., sodium, potassium, chloride, magnesium, calcium) and to identify other biochemical, endocrine or metabolic imbalances that could cause generalized seizures. Drug and alcohol screening may be indicated. Levels of anticonvulsants or other medications may be tested to rule out toxicity or to adjust medication dose for epileptic individuals. A lumbar puncture may be performed if infection is suspected once brain MRI or CT scans have ruled out other possible physiological causes within the brain.

Source: Medical Disability Advisor



Treatment

Treatment is aimed at achieving seizure-free status in the individual without any adverse effects. This includes treating the underlying disorders such as brain tumors, infections, and metabolic or endocrine abnormalities that precipitated the seizures. Anticonvulsant therapy may not be necessary for individuals who have a single seizure. The risk of recurrent seizures depends on age, medical history, and the cause(s) of the seizure.

Anticonvulsant medications are the mainstay of treatment and the specific drugs prescribed depend on the type of seizures and the age of the individual. Some individuals may experience side effects from anticonvulsant medication, and some may continue to have seizures. Single drug therapy is preferred because it decreases the likelihood of adverse effects, but combination drug therapies may be necessary for some individuals. Once seizures are controlled, medications typically are continued for 2 to 5 years (Ko). When the individual is seizure-free and the EEG is normal, medications may cautiously be tapered and then discontinued. Children often outgrow their epilepsy, but the relapse rate in adults is about 40% to 50% after discontinuing medication (Ko). Individuals with uncontrolled seizures are advised not to drive, operate heavy machinery, or work in dangerous situations such as at heights or underwater. Antiepileptic drugs are in development that have shown neuroprotective effects in animal studies and may alter the incidence of adverse-effects.

The vagus nerve stimulator (VNS) is a medical device that can be used to treat resistant (refractory) focal-onset epilepsy in adults. The VNS generator is implanted in the upper left side of the chest and can be activated with a magnet at the beginning of the seizure, stopping or limiting a seizure.

Surgery may be needed to remove resectable lesions such as neoplasms. Surgery to resect the specific areas of the brain that are causing the seizures (epileptic focus) may be an option for individuals (most often children) who do not respond to medication therapy (about one-third of all individuals with seizures (Shafer)).Tests must show that the seizures originate from a focal, resectable, brain region. Individuals with seizures should avoid alcohol, drugs, unnecessary medications, undue stress, improper nutrition, and sleep deprivation. Social and vocational rehabilitation may be recommended for some individuals whose seizures have led to psychosocial disturbances.

Source: Medical Disability Advisor



Prognosis

The outcome in seizure disorders depends on the seizure type, the underlying cause, and the individual's response to treatment. The recurrence rate within 2 years after a first unprovoked seizure varies considerably (15% to 70%) depending on the type of seizure and underlying cause of seizures. Having an abnormal brain MRI, EEG, and a partial-onset seizure increases risk of recurrence (Ko). Anticonvulsant treatments have been reported to reduce seizure recurrence rates (about 18% and 39% of treated individuals and untreated individuals have seizure recurrence within 1 year, respectively) (Ko).

Poor seizure control is associated with epilepsy of longer duration, focal seizures, more seizures before treatment, seizures of known cause, abnormal activity on EEG, frequent seizures, or delay in treatment for a year or more.

Individuals who have recurrent unprovoked seizures have similar mortality and morbidity rates as individuals diagnosed with epilepsy. Death caused by seizure occurs only in a small percentage of epileptic individuals (sudden, unexpected death in epilepsy [SUDEP]). Most deaths are due to self-injury or impaired consciousness. Nevertheless, epilepsy may affect life span, with sudden death due to seizure or irregular heart rhythm (arrhythmia), neurogenic pulmonary edema, or suffocation during an epileptic seizure with impairment of consciousness (Ko).

Source: Medical Disability Advisor



Complications

Injuries including bruising, abrasions, and lacerations of the tongue, face, and limbs may occur during a generalized tonic-clonic seizure. Injuries may be fatal if the individual is driving, at a height, or under water. Fear of loss of control coupled with the demands of ongoing medical treatment may affect employment and lead to social isolation. Anti-epileptic medications may interfere with medications such as birth control pills, thereby leading to unwanted pregnancy. Use of anti-epileptic medications during pregnancy may lead to birth defects, but uncontrolled seizures during pregnancy may pose an additional hazard.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Special precautions should be taken for individuals at risk of recurrent seizures. Individuals may be restricted from operation of machinery or motor vehicles, working at heights, or working in other potentially dangerous situations until seizures are adequately controlled, otherwise restrictions may be permanent. Driving restrictions vary from state to state for individuals with seizure disorders.

Risk: Typical work restrictions for individuals with seizures involve removal from safety-sensitive work tasks and conditions in which significant injury to the self or others could occur during a seizure. Drowsiness from medications may be an additional issue of risk. Company policy on medication usage should be reviewed to determine if medication use is compatible with job safety and function. Recurrence may be reduced by avoiding shift work and getting adequate sleep. No working at unprotected heights.

Capacity: Between episodes, capacity in individuals with seizure disorders is not affected. As long as risk is adequately addressed, individuals with seizures may work without limitations.

Tolerance: Some individuals with seizures may dislike working, fearing that a potentially embarrassing seizure may occur in the workplace. In this case, tolerance becomes an issue of choice (to work or not to work) and is not a reason for reduced capacity or disability.

Source: Medical Disability Advisor



Maximum Medical Improvement

180 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 this episode a first seizure?
  • Was individual previously diagnosed with epilepsy?
  • Did individual have only one seizure or recurrent seizures?
  • Has individual had a witnessed seizure?
  • Does individual have focal or generalized seizures?
  • Does individual have an aura preceding seizures?
  • Does individual or witness report chewing movements or smacking of the lips, numbness or tingling of the limbs or face, twitching of the muscles, and distorted, unpleasant perceptions of odor, vision, or time with their focal seizure?
  • Does individual lose consciousness during seizures?
  • Does individual have tonic posturing and clonic movements? Does individual lose bladder and/or bowel control?
  • Is the seizure followed by lethargy, headache, post-ictal confusion, and muscle soreness?
  • Does individual have absence seizures with 10- to 30-second periods of loss of consciousness, with blank stare and fluttering of the eyelids?
  • Does the individual have myoclonic seizures that are brief and repetitive and are associated with jerking of the limbs?
  • Has the individual had EEG, MRI, CT, blood tests, drug, and alcohol screening? Was a lumbar puncture done?
  • Does individual have any other medical conditions such as stroke, brain tumor, trauma to the brain, central nervous system infection, hypoglycemia, heatstroke, or withdrawal from long-term use of alcohol or drugs? Is individual taking drugs or medications, including anticonvulsants for previous seizures?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Does individual have an underlying medical condition(s) that could be the cause of the seizure? Is it being treated?
  • Is individual being treated with anticonvulsant medications? Are seizures controlled?
  • Is individual a candidate for the vagus nerve stimulator? Has it been implanted?
  • Is individual a candidate for surgery?
  • Was individual advised to avoid alcohol, drugs, unnecessary medications, undue stress, improper nutrition, and sleep deprivation? Is individual compliant?
  • Has individual been educated about avoiding things that could result in self-injury such as driving, operating motorized equipment, heights, swimming, use of stoves?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect the ability to recover?
  • Does the individual have any complications, such as self-injury or social isolation?
  • Would individual benefit from evaluation and treatment of psychosocial effects of epilepsy?

Source: Medical Disability Advisor



References

Cited

AlEissa, Eissa Ibrahim, and Selim R. Benbadis. "First Seizure in Adulthood." eMedicine. 22 May. 2015. Medscape. 3 Aug. 2015 <http://emedicine.medscape.com/article/1186214-overview#showall>.

Ko, David Y. "Epilepsy and Seizures." eMedicine. 2014. Medscape. 3 Aug. 2015 <http://misc.medscape.com/pi/iphone/medscapeapp/html/A1184846-business.html>.

Source: Medical Disability Advisor






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