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.

Sprains and Strains, Rotator Cuff (Capsule)


Related Terms

  • Glenohumeral Dislocation
  • Shoulder Dislocation

Differential Diagnosis

Specialists

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

Factors Influencing Duration

Duration depends on severity of injury. Following surgery, duration depends on whether surgery was open or arthroscopic. If the nondominant side is injured, the individual may be disabled from 1 to 10 weeks. If surgical reconstruction is necessary for the dominant side, additional recovery time will be needed, especially for individuals who perform heavy or overhead work.

Failure to fully rehabilitate the shoulder may lead to repeated injuries and perhaps permanent disability.

Medical Codes

ICD-9-CM:
840.4 - Sprains and Strains of Shoulder and Upper Arm, Rotator Cuff (Capsule)

Overview

The shoulder joint (glenohumeral joint) 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 less bony stability. The shoulder, as a result, 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 that attach to the humerus fuse together to form the rotator cuff.

Accordingly, if the rotator complex weakens in any capacity (including from injury, deconditioning, or aging), the less capable the muscles will be to pull the arm firmly into the shoulder socket or joint. Understanding this relationship provides insight into treatment and outcomes for rotator cuff strains and strains.

A sprain is a stretching or tearing of ligaments—the tough bands of fibrous tissue that connect one bone to another in the body's joints, stabilizing and supporting the joints. A strain is a stretching or tearing of muscle and/or tendon—a fibrous cord of tissue that connects muscles to bones.

However clear the distinction generally remains, in the shoulder, sprains and strains may not be as easily separated as in some other joints. This is because of the anatomy. The muscle and tendons insert into the bone but there are attachments of ligaments that also make up the rotator cuff. Two bones come together at the shoulder, the ball, or humeral head, at the upper end of the arm, and the socket, which is part of the shoulder blade (glenoid of the scapula). Ligaments cross between these two bones and stabilize the glenohumeral joint.

A sprain of the rotator cuff or shoulder capsule occurs when there is a forceful injury to the ligaments that stabilize the shoulder joint. The stretching or partial tearing of these ligaments causes the shoulder joint to become loose (lax) and can lead to complete disruption or dislocation.

Sprains of the shoulder capsule are classified according to the amount of damage to the ligaments and any resulting laxity of the joint. The grading of rotator cuff sprains is not an exact science but based on clinical assessment and experience related to signs, symptoms, or imaging studies.

Mild stretching without tearing of the ligaments is a grade I or first-degree sprain. There may be some minimal instability of the joint at this point.

In a grade II or second-degree sprain, some fibers of the capsule tear, causing the head of the humerus to slip and almost dislocate (subluxation), creating a feeling of instability.

Grade III, or third degree sprains, result in complete disruption of the joint capsule and displacement of the humeral head out beyond the joint (shoulder dislocation). The dislocation can be downward, upward, frontward, or backward (inferior, superior, anterior, or posterior) or result in multidirectional instability, which means the humeral head moves too far in many directions. The most common direction for shoulder dislocation is anterior, followed by posterior, and infrequently is multidirectional.

Sprains with movement of the humeral head toward the front (anterior) are the result of trauma and usually are caused by forced external rotation with the elbow away from the body. This movement is similar to throwing. Acute posterior sprains and dislocations are rare and most often result from a direct blow to the shoulder or outstretched arm. Chronic sprains result when supporting ligaments stretched from repeated injuries do not heal; they also result from changes in the glenoid lip and humeral head when the bones slip out of position.

In addition to sprains, the shoulder can also have strains to the muscle / tendons. Strains may be acute or chronic. In the shoulder for both the strain and sprain, the acute can become chronic in the rotator cuff, which can then lead to degeneration of the cuff and eventually to a complete tear. The exact pathology mechanism is not fully understood.

Acute shoulder dislocations are a true emergency because of the possibility of nerve and vascular damage while the bones are out of position. They require immediate attention, either in a physician's office with x-ray capability, urgent care units, or an emergency room.

Incidence and Prevalence: Estimates suggest that each year 3.7 million individuals in the US visit their physicians for upper arm and shoulder sprains and strains ("Common Shoulder Injuries").

Source: Medical Disability Advisor



Causation and Known Risk Factors

Athletes, especially those who participate in contact sports such as rugby, football, lacrosse, and ice hockey, are among those most likely to sustain a shoulder sprain. Individuals who perform heavy overhead work or heavy lifting are also more likely to experience one.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report a wide variety of symptoms and prior activities. Most individuals will report a traumatic event such as a fall, having their arm jerked backward, or trying to catch something heavy that was slipping. The amount of pain experienced is relative to the grade of sprain. In grade I sprains, individuals may complain of some pain with motion. In grade II sprains, immediate pain will have subsided if the arm bone (humeral head) has returned to its normal position (reduced) and only shoulder motion is painful. Grade III sprains most often present with the individual carrying his or her arm with the elbow bent and away from his body. Individuals may report a feeling of slipping or tearing in the joint. Pain is immediate and does not subside until the shoulder is reduced. If this is a second episode of a grade III sprain or dislocation, the individual may have attempted a self-manipulation or reduction.

Physical exam: A sunken area may be obvious just below the tip of the shoulder (sulcus sign) created by the arm bone being out of position for a dislocation. One diagnostic test is to attempt to move the arm through the throwing motion, checking not only the shoulder function, but also the individual's level of anxiety (apprehension sign). Changes in color, temperature, sensation, and strength may be evident in the arm and hand. Reflexes may be either decreased or accentuated.

Some examples of shoulder specific physical examination tests include: anterior drawer test, apprehension test (anterior and posterior), biceps load test, clunk test, cross-over impingement test, drop arm test, Hawkins test / Hawkins-Kennedy impingement test, Neer impingement test, and Yergason test (Holtby).

Tests: Plain shoulder x-rays (anterior-posterior [AP], lateral, and glenoid views) will demonstrate the position of the humeral head, which defines the direction of any subluxation or dislocation. X-ray examination will also determine the presence of fractures of the shoulder (glenoid fossa, humeral head, clavicle, or acromion). An MRI is indicated if a tear of the rotator cuff is suspected in association with a sprain, or if the sprain resulted from significant trauma. Diagnostic ultrasound may also be performed to help diagnose this condition.

Source: Medical Disability Advisor



Treatment

Treatment for both sprains and strains depends on the grade. The inflammation and pain caused by ligaments stretching and tearing decreases with rest. If bleeding has occurred, scar tissue will form around the ligaments, adding stability and some strength to the joint. Ligaments that are torn away from a bone (avulsed) may reattach themselves if allowed to rest during the healing phase. The term "rest" is relative; motion is often allowed, but not the stress of lifting the arm. Treatment is aimed at reducing further trauma to the joint, regaining motion of the joint, and rehabilitating supporting muscle groups for added stability.

Grade I sprains are treated with relative rest, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) as needed. Strengthening of the shoulder muscles can begin when active range of motion is achieved. A sling with waist strap is worn initially to rest the shoulder, but wrist motion and gripping exercises are encouraged.

Grade II sprains are treated in a similar manner, with relative rest lasting about 2 weeks, allowing scar tissue to form around the ligaments. Strengthening exercises focus on the muscles stabilizing the shoulder to help prevent further subluxations. A sling with waist strap is used initially full-time, even in bed, and then for activities that put the shoulder at risk.

In grade III sprains, the need for shoulder reduction is urgent, but care must be taken to prevent possible nerve and vessel damage from improper manipulation. Most often, no attempt to reduce a first episode dislocation is made without an x-ray examination. Closed relocation of the bones to their anatomically normal position (closed reduction) is possible only when the muscles around the shoulder are relaxed. Medication for relief of pain and muscle relaxation usually is necessary. Pain relief is immediate and often quite dramatic with reduction. A sling or sling with waist strap (sling and swath) is worn for up to 6 weeks, and medication for pain and muscle relaxation is often prescribed. Physical therapy begins after about the first week with a focus on joint mobility and strengthening.

Reconstructive surgery (shoulder capsulorrhaphy) is indicated in younger individuals who have a higher chance of injury recurrence. It usually is indicated after the third dislocation, although some individuals choose to change their lifestyle, reducing the risk of repeated dislocations, instead of undergoing surgery.

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

Relief of pain and regaining a feeling of stability depend on the grade. These may come as early as 1 to 2 weeks as the capsule ligaments heal by scarring and as inflammation of the tissues decreases. This relief is deceptive, especially in grade II and III injuries. The stretched joint capsule takes about 6 weeks to heal, and the shoulder muscles need about 4 weeks of strengthening to maintain stability. Recovery may then take up to 10 weeks.

In grade III sprains or dislocations, adequate reduction is common, but repeated dislocation is frequent without surgical repair. Fractures associated with a grade III sprain or dislocation may indicate a less optimum recovery because of increased instability of the joint. Individuals may continue to experience apprehension when the arm is placed in a vulnerable position.

Individuals who have recurring episodes of dislocation will have a shorter recovery time after each episode but may not be able to return to overhead activities. They are also at greater risk for degenerative arthritis.

Source: Medical Disability Advisor



Rehabilitation

The initial goals of rehabilitation following shoulder capsule sprain are to decrease pain and inflammation associated with the injury and to prevent stiffness and weakness (Cleeman).

The specific rehabilitation program depends greatly on the severity of the injury. After an acute injury, all individuals are prescribed some degree of rest. Individuals with a grade I sprain may need a few days of rest, whereas individuals with complete dislocation (grade III) nearly always are immobilized in an adduction sling, usually up to 3 to 4 weeks. Some physicians may choose immobilization in a position of adduction with mild external rotation to reduce the risk of recurrent dislocation, but this may be poorly tolerated (Itoi). During this time, cold therapy may be used to reduce inflammation. Individuals will be instructed in range of motion exercises for the hand, wrist, and elbow. The individual may be allowed some limited range of motion at the shoulder under therapist supervision (Curtis), and may be taught isometric strengthening exercises (Cleeman).

Once adequate healing has occurred, therapy helps the individual regain range of motion and improve strength (Hayes). To achieve these goals, the individual performs a progressive range of motion and strengthening program for the shoulder (Liu). The specific timing of these exercises will vary with the severity of injury. Generally, individuals with a grade I sprain will be able to begin range of motion and strengthening immediately after the acute phase. However, for individuals with dislocations, only progressive range of motion exercises and isometrics are performed for the 4 weeks following the immobilization period (Bottoni). Abduction and external rotation are avoided for 6 weeks to reduce the risk of dislocation (Curtis). All exercises and daily activities will need to be limited to a pain-free range of motion, so as to not impede the continued healing of the injured capsule.

In a grade III sprain, the individual must wait until 9 to 12 weeks after injury to begin strengthening exercises that involve joint movements (Curtis). At this stage, strength training may include weight equipment/machines, elastic bands, or manual resistance from the therapist. The strengthening program will focus on shoulder girdle, upper trunk, and upper arm musculature (Cleeman; Liu), and should include an emphasis on rotator cuff and scapular stabilizers (Curtis). Strengthening exercises intensify as the individual's pain decreases and as strength increases. Individuals should be instructed in a home program that reflects the exercise regime prescribed during rehabilitation.

An individual with full range of motion and strength may still be at risk of re-injury, so the final component of rehabilitation should include advanced exercises to stabilize the shoulder joint. By 4 months, an individual whose case is uncomplicated should be able to return to contact sport or other highly aggressive activities (Bottoni).

In grade I and grade II injuries, conservative management is usually effective. In a grade III injury, complete dislocation of the glenohumeral joint can occur, and surgical intervention may be needed. See Dislocation, Glenohumeral.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Rotator Cuff (Capsule)
Physical or Occupational TherapistUp to 8 visits within 6 weeks
Surgical
SpecialistSprains and Strains, Rotator Cuff (Capsule)
Physical or Occupational TherapistUp to 12 visits within 8 weeks
Note on Nonsurgical Guidelines: Degree of injury will determine when rehabilitation can be started.
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

Complications are rare with grade I and grade II. Each time the shoulder capsule is injured, more damage is done to the supporting ligaments, and the laxity of the joint is increased. Increasing laxity, in turn, increases the chance of repeated sprains and the onset of impingement syndrome.

Complete tears of the rotator cuff and a pulling away of its attachment to the arm (avulsion of the greater tuberosity) may occur during a severe sprain. These tears may require early surgical repair.

Any fractures that occur during a grade III sprain (dislocation) change the anatomy of the shoulder and the mechanical action of the joint. Especially troublesome are fractures of the upper arm bone (humeral head) or shoulder blade (scapula, glenoid). These fractures may require surgical correction to restore normal anatomy, allowing the shoulder to be stable. Stability of the shoulder is critical in preventing recurring sprains of the shoulder capsule.

Nerve or blood vessel injury from the dislocation will need attention immediately.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

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. Reaching and arm use above shoulder level should be avoided. Limiting use of the affected shoulder or avoiding use completely may be necessary. Use of a sling, or a sling and swathe, is recommended for grade I and grade II sprains and is mandatory for first-time dislocations (grade III injuries). Use of a sling limits manual dexterity and may prove hazardous to the individual or those around him or her. Individuals whose work environment places them at risk for recurrent episodes may be asked to wear a protective harness, the use of which may become permanent. Overhead use of the arm is restricted with this device. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. .

Physical therapy may be needed for months until the pain is gone and the individual regains use of his or her shoulder. Access to ice for control of pain and swelling will allow earlier return to work after injuries involving the nondominant arm. The arm and hand can be used at the individual's non injured side for activities that do not require lifting, pushing, or carrying. These restrictions may become permanent.

Tolerance and accommodation determine the final ability to return to work. Modifications to the workplace or modifications to the job task may allow many individuals to return to modified work. Changing job duties, sharing or alternating tasks, working at a reduced rate, taking more frequent rest breaks, and limiting the time and frequency of repetitive activities are important accommodations. Older individuals may recover more slowly and may not be able to regain adequate strength and stability to resume strenuous activities that stress the shoulder.

For more information, refer to "Work Ability and Return to Work," pages 179-184. Users may find it helpful to read Chapters 1-3 in "Work Ability and Return to Work," which provide a framework for considering the benefits of staying at—or returning to—work.

Risk: Reinjury 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 have less recurrence than older individuals or those not in good physical condition (who have less endurance).

Tolerance: Tolerance is the limiting issue for shoulder impingement. Non-surgical treatment with modification to work can often result in improvement without surgery. Education can help the individual understand the risks of reinjury and can improve his or her tolerance during the non-surgical treatment period. Unfortunately, many individuals elect surgery in the hopes of a quick fix. Tolerance (the ability to work through the pain) is unique to each individual.

Accommodations: Accommodations and patience are the key. Most individuals will get better with time and therapy. Employer willingness to accommodate the employee allows the individual time to recover.

Aggravating activities need to be avoided or limited until symptoms have been relieved. During early treatment, the individual should avoid lifting, carrying, pushing, or pulling heavy objects. Individuals should avoid activities with the arm above shoulder level. The above guides are only temporary and are rarely permanent. Examples of accommodated work might include 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.

An ergonomic evaluation of the workplace may be necessary. Work site modifications can include forearm rests for individuals who use computer keyboards frequently, headsets for those who answer telephones, and modifications such that repetitive activities are performed 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.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of fracture, dislocation, nerve injury, or spinal cord injury, the cervical sprain/strain is considered a “soft tissue injury.” Like other soft tissue injuries, the majority of the healing occurs in the first 3 months. Other than surgery, additional treatment after 3 months from the date of injury is not likely to result in dramatic improvement, so MMI is frequently achieved by 3 months after 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:

  • Was the sprain classified as grade I, II, or III?
  • What was the mechanism of injury?
  • Was a deformity noted on exam?
  • Was this a first-time sprain or a repeat sprain?
  • If a repeat or chronic sprain, is it related to job requirements such as overhead work?
  • What level of pain did individual have?
  • Was individual able to move the arm? What was the level of anxiety?
  • Were individual's reflexes decreased or accentuated?
  • Did individual have plain x-rays? MRI or other imaging tests?
  • Were there any signs of nerve or vascular damage or associated fractures?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Is individual giving the affected joint and arm appropriate rest using a sling?
  • Is individual using ice and NSAIDs?
  • Is individual continuing to use the wrist? Doing gripping exercises?
  • Was the acute sprain reduced on an emergency basis?
  • Was a closed reduction done?
  • Was surgery necessary?
  • Have medication for pain and muscle relaxation been prescribed?
  • Was physical therapy started at the appropriate time? Is physical therapy continuing?

Regarding prognosis:

  • Is individual active in physical therapy? Is individual doing exercises at home?
  • Is the injury on the dominant or nondominant side?
  • If necessary, does individual wear a protective harness?
  • Does individual have any conditions that may affect ability to recover?
  • Has individual developed degenerative arthritis?
  • Has individual had other complications such as repeated strains or impingement syndrome?
  • Would individual benefit from additional physical therapy?
  • Is individual's employer able to accommodate any necessary restrictions?

Source: Medical Disability Advisor



References

Cited

"Common Shoulder Injuries." American Academy of Orthopaedic Surgeons. Aug. 2007. American Association of Orthopaedic Surgeons. 23 Mar. 2009 <http://orthoinfo.aaos.org/topic.cfm?topic=A00327>.

Bottoni, C. R., et al. "A Prospective Randomized Evaluation of Arthroscopic Stabilization Versus Nonoperative Treatment in Patients with Acute, Traumatic, First-Time Shoulder Dislocations." American Journal of Sports Medicine 30 4 (2002): 576-580. National Center for Biotechnology Information. National Library of Medicine. 1 Oct. 2008 <PMID: 12130413>.

Chen, S., et al. "The effects of thermal capsular shrinkabe on the outcomes of arthroscopic stabilization for primary anterior shoulder instability." American Journal of Sports Medicine 33 5 (2005): 705-711. PubMed. 11 Nov. 2010 <PMID: 15722277>.

Cleeman, E., and E. L. Flatow. "Shoulder Dislocations in the Young Patient." Orthopedic Clinics of North America 31 2 (2000): 217-229. National Center for Biotechnology Information. National Library of Medicine. 1 Oct. 2008 <PMID: 10736391>.

Curtis, Ralph J. "Section H - Chapter 17 - Glenohumeral Instabilites: 2. Glenohumeral Instabilities in the child." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse C. DeLee and David Drez. 2 ed. Saunders Elsevier, 2003.

Hayes, K., et al. "Shoulder Instability: Management and Rehabilitation." Orthopedic and Sports Physical Therapy 32 10 (2002): 497-509. National Center for Biotechnology Information. National Library of Medicine. 1 Oct. 2008 <PMID: 12403201>.

Holtby, R. , and H. Razmjou. "Accuracy of the Speed's and Yergason's Tests in Detecting Biceps. Pathology and SLAP Lesions: Compared With Arthroscopic Findings. Arthroscopy." The Journal of Arthroscopy and Related Surgery 20 (2004): 231-236.

Itoi, E., et al. "A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study." Journal of Shoulder and Elbow Surgery 12 5 (2003): 413-415.

Liu, S. H., and M. H. Henry. "Anterior Shoulder Instability. Current Review." Clinical Orthopaedics and Related Research 323 (1996): 327-373. National Center for Biotechnology Information. National Library of Medicine. 17 Dec. 2004 <PMID: 8625601>.

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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