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.

Subarachnoid Hemorrhage (Non-traumatic)


Related Terms

  • Ruptured Arteriovenous Malformation
  • Ruptured Cerebral Aneurysm
  • Spontaneous Atraumatic Intracranial Hemorrhage

Differential Diagnosis

Specialists

  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Speech Therapist

Comorbid Conditions

Factors Influencing Duration

Disability factors include the location and extent of hemorrhage within the brain, underlying cause of the hemorrhage, age and general health of the individual, job requirements, severity of residual brain damage, and success of treatment measures directed at eliminating the cause of the hemorrhage.

Medical Codes

ICD-9-CM:
430 - Subarachnoid Hemorrhage

Overview

© Reed Group
A subarachnoid hemorrhage (SAH) refers to the leakage of blood into the subarachnoid space containing the cerebrospinal fluid (CSF). The subarachnoid space is located between the arachnoid membrane and the pia mater; the arachnoid membrane is the middle of three membranes (meninges) that surround the brain and spinal cord. The pia mater is the innermost layer of the meninges and closely lines the brain and the spinal cord; the dura mater is the outermost and toughest of the three meninges and lines the inner surface of the skull.

SAH may result from head trauma, rupture of a dilated blood vessel (cerebral aneurysm), or leakage from a complex cluster of thin-walled arteries and veins called arteriovenous malformation (AVM). Cerebral aneurysms are also referred to as "berry" aneurysms because of their shape. They may be congenital (present at birth) and later rupture when an individual reaches their 30s or 40s. Other possible causes of SAH are bleeding disorders such as hemophilia or a reduced ability to clot (altered hemostasis) from excessive use of anticoagulant medications.

Incidence and Prevalence: Incidence rates vary worldwide, with higher incidence rates in Finland and Japan. The incidence increases with age, especially in women over the age of 50 (Vlak).

Source: Medical Disability Advisor



Causation and Known Risk Factors

SAH is more frequent in women after the age of 50. Overall the female-to-male ratio is 3 to 1 (Caranci). Intracranial aneurysms (IA) affect 5% to10% of the population, but only a small fraction will rupture. Early retrospective studies suggested that IA size may be the main predictor of rupture with SAH, with annual rupture rates of 3.3% per year for those 10 mm to 15 mm, 5.6% per year for those 16 mm to 25 mm, and 8.9% per year for those larger than 25 mm, but the causes of rupture are still under intense study (Caranci). About 80% of cases of SAHs without trauma are caused by aneurysms (Brown). Individuals with a family history of SAH are at an increased risk for developing SAH.

The four most important risk factors for SAH secondary to a ruptured IA are smoking, family history (increases with number of first-degree relatives affected), hypercholesterolemia, and high blood pressure (hypertension). Excessive alcohol use and lack of physical exercise are also risk factors (Vlak).

There are also several heritable conditions that are associated with SAH including autosomal dominant polycystic disease, neurofibromatosis type I, Marfan syndrome, multiple endocrine neoplasia type I, pseudoxanthoma elasticum, hereditary hemorrhagic telangiectasia, and Elhers-Danlos syndrome type II and IV. These conditions account for a small portion of cases (Caranci). Rarely, a history of an infection in the heart (endocarditis) may also be associated with SAH.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may report the abrupt onset of a severe, throbbing headache that is localized initially before spreading to other areas. Additional symptoms include dizziness, rigid (stiff) neck, nausea, vomiting, drowsiness, sweating, sensitivity to light (photophobia), double vision (diplopia), weakness on one side of the body (hemiparesis), chills, and decreased consciousness.

Physical exam: The individual's level of consciousness may vary from alert to comatose. Partial paralysis, dilation of one or both pupils, and/or a stiff neck may be present. Blood pressure is often elevated.

Tests: Blood tests such as complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), electrolytes, cardiac enzymes, arterial blood gas (ABG), and type and screen (T&S) can help in the initial evaluation of the individual. Transcranial Doppler, chest x-ray (CXR), and electrocardiogram (ECG) are also indicated. The most frequently used diagnostic test involves the use of a computed tomography (CT) to visualize the area affected by the bleeding, as well as the source of hemorrhage. CT is better than magnetic resonance imaging (MRI) because MRI may not detect SAH early on. However, CT is not always positive in an individual with SAH. If results are negative and the history is compelling, a spinal tap (lumbar puncture, LP) is done to look for blood in the CSF. This procedure involves inserting a needle into the subarachnoid space in the lower spinal column and removing a small amount of CSF. Intracranial pressure (ICP) is then measured using a screw-type device or catheter with a sensor tip inserted through a burr hole in the skull. LP is contraindicated if increased ICP is suspected because the sudden decrease in CSF pressure may disrupt the clot on a ruptured aneurysm, with further bleeding. Sometimes cerebral angiography is done to identify the exact source of hemorrhage (e.g., AVM or aneurysm).

Source: Medical Disability Advisor



Treatment

Treatment focuses on first locating the source of SAH and, if possible, surgically repairing the aneurysm or AVM to stop the bleeding. The best time to perform surgery remains controversial. Early surgery (within the first 3 days) reduces the chances of rebleeding, but delayed surgery (after 14 days) avoids the time between 3 and 14 days when abnormal contraction of arteries (vasospasm) and its consequences are greatest. In general, individuals who are conscious with a minimal neurologic deficit on arrival do best with early surgery, whereas obtunded individuals do better with delayed surgery.

Ruptured IAs are corrected surgically using one of three procedures: aligning the edges of the ruptured aneurysm to stop the bleeding with stainless steel or cobalt alloy clips (clipping), tying off the bleeding blood vessel with suture (ligation), or filling of the aneurysm body with platinum coils delivered through a microcatheter that is passed from the femoral artery into the aneurysm neck (coiling). The best way to prevent SAH from rupture of a IA is to diagnose and surgically correct the aneurysm before it ruptures.

Once an aneurysm is treated, follow-up focuses on preventing complications such as rebleeding, secondary cerebral vasospasm, abnormal amounts of CSF collecting around the brain (hydrocephalus), seizures, the effects of elevated ICP, and a low sodium concentration in the blood (hyponatremia) due to a "cerebral salt-wasting syndrome" secondary to altered secretion of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), and to the inappropriate release of a hormone called antidiuretic hormone from the pituitary gland (syndrome of inappropriate antidiuretic hormone [SIADH] secretion) (Hannon).

Secondary vasospasm, that may cause focal brain ischemia, may be prevented by the use of the calcium channel blocker nimodipine. Large amounts of intravenous (IV) fluid may be administered to treat vasospasm by increasing blood pressure to enhance blood flow to the brain (triple-H method: hypertension, hemodilution, and hypervolemia). This increased blood flow ensures an adequate oxygen level to the brain and minimizes damage to the surrounding brain tissue; however, evidence of the effectiveness of this approach is inconclusive.

Draining excess CSF though a shunt into the abdominal or chest cavity or into the heart typically treats hydrocephalus. If hydrocephalus is not controlled, brain tissue damage can occur as a result of compression of the brain from the excess fluid. Osmotic agents such as mannitol, as well as mild hyperventilation and sedation, may also be used in an effort to temporarily control increased ICP.

Source: Medical Disability Advisor



Prognosis

The prognosis associated with a SAH is multifactorial, primarily driven by the severity of the initial bleed (Khatri). However, SAH causes death in over 10% of individuals who cannot make it to the hospital in time to be treated; even those individuals with nontraumatic SAH who make it to the hospital in time have about 50% chance of dying (van Gijn). Among those individuals who survive SAH at least 3 months, the risk of complications and death is increased. The risk of all-cause death, vascular death and fatal and nonfatal vascular disease is significantly increased among those with previous SAH (Nieuwkamp).

Source: Medical Disability Advisor



Rehabilitation

Individuals who sustain nontraumatic SAH may require a wide array of rehabilitation services. The type and length of rehabilitation depend on the severity of residual brain damage as a result of the hemorrhage. Individuals may present with a variety of physical and cognitive disabilities, depending on the severity of the injury. They may need to be treated by physical, occupational, and speech therapists, as well as neuropsychologists, vocational counselors, and social workers.

Individuals may demonstrate motor control deficits. Physical and occupational therapists treat any balance and coordination disorders. Individuals with impaired coordination perform fine motor coordination exercises in occupational therapy and work on gross motor coordination in physical therapy. For example, occupational therapists may work on dynamic sitting balance to promote dressing and grooming abilities. Physical therapists may focus on standing balance to preserve the individual's ability to walk. Since individuals with motor control deficits may also have difficulty planning out movements (apraxia), therapists may need to provide cues.

The main focus of physical and occupational therapy in the area of motor control is to maximize functional capabilities. Occupational therapists teach individuals skills to help them with the activities of daily living and may order adaptive equipment to make these tasks easier. Physical therapists teach skills such as getting in and out of bed, walking, or using a wheelchair. Physical therapists may also refer an individual to an orthotist, if leg braces are deemed appropriate.

Individuals with poor motor control of the facial muscles may require speech therapy to improve their clarity of speech and ensure their safety in swallowing. Speech therapy teaches individuals to learn or relearn to pronounce certain speech sounds. Individuals also learn to change speech patterns, such as decreasing the speed of speech or changing the volume of speech. Individuals learn to speak with greater volume through activities such as sustained vocal expressions, for example, saying "ah." Speech therapy can also strengthen the muscles of the face for improved speech and swallowing. Individuals learn to move the facial muscles in a balanced manner, using both manual assistance and visual cueing. Individuals perform tongue exercises to allow for better speech and eating. Individuals who cannot talk because of motor deficits may require adaptive devices such as communication boards or computers that "talk" for the individual when words are entered into it.

Individuals may also suffer from perceptual deficits. Occupational and physical therapists provide methods to increase safety, such as teaching the use of a cane to compensate for decreased balance due to diplopia. Individuals may require an occupational or physical therapist to assess their homes to remove tripping hazards. Individuals may present with difficulty speaking or understanding speech (aphasia) due to brain injury. Speech therapy may focus on skills such as word finding and sentence completion. Individuals with hearing loss also may require speech therapy. Speech therapists can teach lip reading or sign language for communication and can provide suggestions for coping with hearing loss. Speech therapists can also assist individuals in obtaining equipment to compensate for hearing loss that uses flashing lights instead of sound as a signal.

Individuals may present with persistent fatigue after a SAH. Occupational therapists may teach energy conservation techniques, in which activities of daily living are broken up into smaller components, thereby making tasks more manageable. Physical therapy addresses decreased endurance by teaching stretching and strengthening exercises of the arms and legs to improve overall endurance. Individuals may also perform aerobic activity to further increase endurance. For individuals in a persistent vegetative state as a result of SAH, physical and occupational therapists teach family members stretching exercises and positioning techniques to prevent pressure sores and joint contractures.

Individuals may also present with cognitive deficits. Occupational therapists evaluate and treat any deficits that are present, and teach individuals to compensate for cognitive deficits by making lists.

Treatment by a neuropsychologist may be necessary for individuals with more severe deficits. Individuals are assessed in areas such as planning, perception, concentration, attention span, orientation, memory, problem solving, and social judgment. Neuropsychologists apprise the therapy disciplines of changes in these areas and help to guide the course of rehabilitation. Neuropsychologists also help individuals and their families make long-range decisions.

Social workers coordinate the care of individuals in areas ranging from discharge planning to obtaining different services, as well as arranging for any adaptive equipment that may be necessary. Individuals may learn of support groups for people with similar disabilities.

Vocational counselors work with occupational, physical, and speech therapists to replicate job task requirements in therapy. These counselors may help individuals keep future career plans realistic and ease the transition back to work. Vocational counselors may also focus individuals on new careers that may be more appropriate under their current level of disability.

Source: Medical Disability Advisor



Complications

Complications include seizures, infection after surgery, long-lasting neurologic deficits, recurrent bleeding (7%), and hydrocephalus (Jung; Kahtri; Naidech). Some SAHs are associated with extension of bleeding into the brain itself, thereby complicating treatment and worsening the prognosis. Another complication of SAH is hyponatremia.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Significant work restrictions and accommodations are often required. If the individual was working before the SAH, he or she may require transfer to a more sedentary and less physically and emotionally demanding position. In addition, loss of some cognitive function and/or residual partial paralysis may dictate the need for reassignment or may mandate medical retirement.

Risk: Jobs with high risk of head injury should be avoided. There is no harm in performing work tasks that the individual has adequate intellect and motor skills for, as the brain does not become injured or get worse with activity.

Capacity: Capacity may be affected in individuals who sustained permanent damage following SAH. Functional testing or a trial of supervised work activity may be helpful in determining work ability.

Tolerance: Tolerance may be affected in individuals who experience a permanent deficit from SAH. Personality changes found in severe SAH may become significant obstacles to return to work because of changes in motivation and effort.

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:

  • Did SAH occur as the result of a ruptured blood vessel in the brain, AVM, bleeding disorder, or head trauma?
  • Does individual have a history of hypertension, endocarditis, or polycystic disease of the kidneys?
  • Did individual exhibit symptoms such as an abrupt onset of a severe, throbbing headache, dizziness, neck stiffness, vomiting, drowsiness, sweating, facial droop, weakness, photophobia, chills, and decreased level of consciousness?
  • Were the presenting symptoms and clinical history consistent with the diagnosis of SAH?
  • Was the diagnosis confirmed with CT, LP, and/or cerebral angiogram?
  • If the diagnosis was uncertain, were other conditions, such as brain tumor, infection, abscess, intracerebral hemorrhage, meningitis, or acute migraine headache, ruled out?
  • Would individual benefit from consultation with a neurosurgeon?

Regarding treatment:

  • Was individual given appropriate stabilization and supportive care (intensive monitoring, bed rest, avoidance of bright lights and noises, blood pressure stabilization)?
  • Did individual suffer any deterioration of neurological status or bleeding or vasospasm?
  • Were appropriate medications administered to reduce bleeding and vasospasm?
  • Was surgery performed within 3 to 14 days following the initial SAH?

Regarding prognosis:

  • Does individual have any persistent or permanent neurological deficits?
  • Is the individual involved in rehabilitative therapy?
  • What is individual's age and general state of health at time of onset?
  • Were there any complications, such as seizures, infection after surgery, long-lasting neurologic deficits, recurrent bleeding, hydrocephalus, or hyponatremia that may have influenced prognosis?
  • What was the expected outcome?

Source: Medical Disability Advisor



References

Cited

Brown, R. D. "Unruptured Intracranial Aneurysms." Seminars in Neurology 30 (2010): 537-544.

Caranci, F. , et al. "Epidemiology and Genetics of Intracranial Aneurysms." European Journal of Radiology 82 (2013): 1598-1605.

Gershon, Abner. "Imaging in Subarachnoid Hemorrhage." eMedicine. Eds. Eugene C. Lin, et al. 30 Jul. 2014. Medscape. 7 Nov. 2014 <http://emedicine.medscape.com/article/344342-overview>.

Hannon, M. J., and C. J. Thompson. "The Syndrome of Inappropriate Antidiuretic Hormone: Prevalence, Causes and Consequences." European Journal of Endocrinology 162 Suppl 1 (2010): S5-S12.

Jung, C. S., et al. "CSF and Serum Biomarkers Focusing on Cerebral Vasospasm and Ischemia after Subarachnoid Hemorrhage." Stroke Research and Treatment 2013 (2013): 560305.

Khatri, R., et al. "Outcomes after Nontraumatic Subarachnoid Hemorrhage at Hospitals Offering Angioplasty for Cerebral Vasospasm: A National Level Analysis in the United States." Neurocritical Care 15 (2011): 34-41.

Naidech, A. M., et al. "Predictors and Impact of Aneurysm Rebleeding after Subarachnoid Hemorrhage." Archives of Neurology 62 (2005): 410-416.

Nieuwkamp, D. J. , et al. "Excess Mortality and Cardiovascular Events in Patients Surviving Subarachnoid Hemorrhage: A Nationwide Study in Sweden." Stroke: A Journal of Cerebral Circulation 42 (2011): 909-907.

Oman, Jennifer. "Subarachnoid Hemorrhage Surgery." eMedicine. Eds. Allen R. Wyler, et al. 15 Mar. 2012. Medscape. 7 Nov. 2014 <http://emedicine.medscape.com/article/247090-overview>.

van Gijn, J. , R. S. Kerr, and G. J. Rinkel. "Subarachnoid Haemorrhage." Lancet 369 (2007): 306-318.

Vlak, M. H. , et al. "Lifetime Risks for Aneurysmal Subarachnoid Haemorrhage: Multivariable Risk Stratification." Journal of Neurology, Neurosurgery, and Psychiatry 84 (2013): 619-623.

Vlak, M. H. , et al. "Prevalence of Unruptured Intracranial Aneurysms, with Emphasis on Sex, Age, Comorbidity, Country, and Time Period: A Systematic Review and Meta-Analysis." Lancet Neurology 10 (2011): 626-636.

Source: Medical Disability Advisor






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