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.

Thrombocytopenia


Related Terms

  • Low Platelets

Differential Diagnosis

  • Conditions of bone marrow failure, such as myelofibrosis and aplastic anemia
  • Connective tissue disease, particularly systemic lupus erythematosus
  • Infection, such as HIV or ehrlichiosis
  • Malignancy
  • Radiation
  • Rheumatic diseases
  • Use of any drugs associated with thrombocytopenia
  • Vitamin B12 or folate deficiency

Specialists

  • Emergency Medicine Physician
  • General Surgeon
  • Immunologist
  • Infectious Disease Internist
  • Oncologist
  • Rheumatologist

Comorbid Conditions

Factors Influencing Duration

Factors include the underlying cause, severity of the disease, need for and response to treatment, whether or not removal of the spleen is performed, and level of strenuous activity in daily life.

Medical Codes

ICD-9-CM:
287.30 - Purpura and Other Hemorrhagic Conditions, Primary Thrombocytopenia Unspecified; Megakaryocytic Hypoplasia
287.31 - Primary Thrombocytopenia, Immune Thrombocytopenic Purpura; Idiopathic Thrombocytopenic Purpura; Tidal Platelet Dysgenesis
287.32 - Primary Thrombocytopenia, Purpura and Other Hemorrhagic Conditions, Evans Syndrome
287.33 - Primary Thrombocytopenia, Purpura and Other Hemorrhagic Conditions, Congenital and Hereditary Thrombocytopenic Purpura; Congenital and Hereditary Thrombocytopenia; Thrombocytopenia with Absent Radii (TAR) Syndrome
287.39 - Primary Thrombocytopenia, Purpura and Other Hemorrhagic Conditions; Other Primary Thrombocytopenia
287.49 - Other Secondary Thrombocytopenia; Thrombocytopenia (Due to): Dilutional, Drugs, Extracorporeal Circulation of Blood, Massive Blood Transfusion, Platelet Alloimmunization, Secondary NOS
287.5 - Thrombocytopenia, Unspecified

Overview

Thrombocytopenia refers to an abnormally low number of platelets or thrombocytes (cell fragments derived from precursor megakaryocytes, which are produced in the bone marrow and help form blood clots to stop bleeding). Thrombocytopenia is a platelet count of less than 50,000 per microliter of blood; the normal range is 150,000 to 450,000 platelets per microliter. A reduction in the number of platelets may result in bleeding, especially from the smaller vessels.

Thrombocytopenia is a sign of many conditions, not a disease. Its causes may be grouped into three categories: decreased platelet production in the bone marrow, increased platelet destruction, and abnormal platelet pooling in the spleen.

Decreased platelet production can occur when bone marrow activity is impaired. This impairment may occur as the result of certain drugs, including ethanol and many antibiotics, or as the result of certain infections, such as HIV or infectious mononucleosis. Other causes of decreased production include vitamin B12 deficiency (pernicious anemia), folate deficiency, aplastic anemia, leukemia, and marrow infiltration (myelophthisic anemia).

Increased platelet destruction is often related to a condition involving the immune system. In immune thrombocytopenia, platelets are destroyed by antibodies created by the individual's own immune system. In post-transfusion thrombocytopenia, platelets are destroyed by antibodies following a blood transfusion. Immune thrombocytopenia may be associated with certain connective tissue diseases, such as systemic lupus erythematosus (SLE); lymphoproliferative diseases, such as chronic lymphocytic leukemia; or infections, such as the tickborne bacterial infection ehrlichiosis. Certain drugs, particularly the anticoagulant heparin, may also induce immune thrombocytopenia. Up to 5% of individuals receiving heparin may develop thrombocytopenia (Watson).

Idiopathic thrombocytopenic purpura (ITP) is considered an autoimmune disease in which the body's own defenses attack and destroy the platelets.

Non-immune conditions that increase platelet destruction include mechanical damage, such as that caused by a mechanical heart valve or by the use of certain drugs. The familial form of thrombotic thrombocytopenic purpura (TTP) is a serious non-immune condition in which platelets clump together; it is accompanied by other abnormalities, such as hemolytic anemia and kidney dysfunction, and may be associated with infection. (There is also an acquired form of TTP that depends on autoimmune mechanisms [autoantibodies].) Hemolytic-uremic syndrome (HUS) is a similar serious condition characterized by hemolytic anemia, thrombocytopenia and kidney failure; this syndrome is associated with E. coli infection; HUS is rare in adults.

Abnormal platelet pooling resulting in thrombocytopenia may occur with an enlarged spleen (hypersplenism), in which up to 90% of platelets are sequestered from the circulation. A variety of conditions may cause hypersplenism, including liver disease.

Thrombocytopenia may develop during pregnancy (6% to 10% of pregnant women), particularly in the third trimester, and may have diverse etiologies. In many cases, it is believed to be a manifestation of pre-eclampsia or eclampsia.

Incidence and Prevalence: The incidence of thrombocytopenia is not well established but is likely in the range of 4.5 out of 100,000 women and 3.2 out of 100,000 men for ITP (Abrahamson), and 1 in 100,000 for TTP ("Thrombotic Thrombocytopenic Purpura (TTP)").

Source: Medical Disability Advisor



Causation and Known Risk Factors

ITP is most common in children and during late adulthood. In adults, women are about twice as likely to be diagnosed with this disease although this difference virtually disappears among older adults (Segal).

Source: Medical Disability Advisor



Diagnosis

History: Symptoms are dependent on the platelet count. Bleeding only becomes evident when the count drops to a certain point. Individuals usually report bruising, bleeding gums, nosebleeds, excessive bleeding from minor cuts, bloody stools (hematochezia or melena), or prolonged or heavy menstrual bleeding (menorrhagia). Headache and dizziness may indicate a risk of brain hemorrhage.

Physical exam: The individual may have small capillary hemorrhages (petechia) or larger bruises (ecchymoses) under the skin. An enlarged spleen may be felt when the physician examines the abdomen by pressing on it with the fingers (palpation).

Tests: A complete blood count (CBC) shows a decrease in the number of platelets. Immature platelets may be seen on a peripheral blood smear. Bone marrow aspiration and biopsy will confirm whether the marrow is involved. Coagulation tests to check platelet function and look for other clotting abnormalities include bleeding time, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and platelet aggregation studies. Additional tests will be performed as needed and may include liver function tests (LFT), platelet antibody tests, and tests to identify infections, such as HIV and ehrlichiosis, and connective tissue diseases, such as systemic lupus erythematosus.

Source: Medical Disability Advisor



Treatment

Mild to moderate thrombocytopenia may not require treatment. General caution, however, dictates that in individuals with thrombocytopenia invasive procedures or injury be avoided and, if possible, any drug that may affect platelets, such as aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) be also avoided. Treatment may be needed only when the individual has had a traumatic injury or is preparing for surgery.

In more significant thrombocytopenia, treatment addresses the underlying cause of the thrombocytopenia. For possible drug-induced thrombocytopenia, all drugs that could reduce the numbers of platelets must be discontinued. Only medically necessary drugs should be continued. In individuals with ITP, if the condition is life-threatening, intravenous immune globulin should be given. If infection is present, treatment must be directed primarily at clearing the infection. Malignancy-caused thrombocytopenia is treated with appropriate chemotherapy for the causal neoplasm. Removal of the spleen (splenectomy) may be beneficial if the spleen is sequestering platelets.

Immune thrombocytopenia is initially treated with immunosuppressant glucocorticoid drugs until platelet counts return to normal. At that time the glucocorticoids should be tapered off. Individuals with chronic thrombocytopenia may need additional treatment cycles to maintain an adequate platelet count. Individuals with severe bleeding are hospitalized and treated with intravenous glucocorticoids plus high-dose immune globulin (immune globulin increases platelet survival time). If the bleeding is life-threatening, platelet transfusions may also be given. Splenectomy is beneficial for individuals who do not respond to steroid therapy or require unacceptably high doses to maintain adequate platelets. Although in immune thrombocytopenia the spleen does not sequester platelets, it does produce the antibodies that attack the platelets. Removing the spleen removes the source of the destructive antibodies.

Thrombotic thrombocytopenic purpura, severe thrombocytopenia in pregnancy, and post-transfusion thrombocytopenia are treated with plasma exchange (plasmapheresis). Immune globulin is also given when needed.

Source: Medical Disability Advisor



Prognosis

Many cases of thrombocytopenia resolve when the offending agent is removed. For example, thrombocytopenia caused by ethanol responds within 10 to 14 days after the removal of ethanol. Once a viral infection is cleared, the platelet count generally rises immediately. In pregnancy, thrombocytopenia usually resolves following delivery.

In immune thrombocytopenia, immunosuppressant glucocorticoid treatment usually reduces bleeding within 1 day and raises platelet counts within 1 to 3 weeks. Most individuals respond to this treatment, but many will relapse once the treatment has stopped and will require additional treatment cycles. Approximately 90% of individuals with immune thrombocytopenia develop a chronic condition and require ongoing treatment (Stasi). Splenectomy will bring about complete remission in about 66% of individuals with immune thrombocytopenia (Kojouri). Thrombotic thrombocytopenic purpura has an 80% to 90% response rate to timely plasmapheresis (George).

Source: Medical Disability Advisor



Complications

If the individual's platelet counts drop to a dangerously low level, severe, even life-threatening, bleeding can occur, particularly inside the brain (intracranial hemorrhage). Splenectomy carries a risk of infection.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals who have significantly decreased platelet counts need a safe work environment that reduces the risk of personal injury, which could trigger an acute bleed. Where indicated, protective gear, especially for the head, should be worn. Office work or sedentary work would probably be more appropriate than strenuous work involving heavy lifting or other physical exertion. The treating physician might advise the employer of how to provide the appropriate level of care quickly in the event of an on-the-job injury. Once the individual's platelet counts have returned to normal, no work restrictions should be needed. Time off will be needed if splenectomy or hospitalization is required.

Risk: In persistent low platelet conditions, jobs at high risk of trauma are probably best avoided. This would most likely include public safety occupations and assembly work involving fast-moving machines.

Capacity: With thrombocytopenia alone, there should be no impact on capacity. If there is associated anemia, then capacity can be measured using stress echocardiogram (ECHO) and pulmonary function tests (PFTs) to ensure adequate reserve for return to work.

Tolerance: If the thrombocytopenia is chronic and benign, tolerance will not be an issue. If the thrombocytopenia is secondary to chemotherapy, then tolerance may be affected by symptoms (nausea, diarrhea, fatigue); however, many individuals will choose to work despite symptoms.

Source: Medical Disability Advisor



Maximum Medical Improvement

90 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:

  • Does individual have an underlying condition that is causing thrombocytopenia?
  • Does individual have idiopathic thrombocytopenic purpura (ITP)?
  • Does individual have bruising, bleeding gums, or nosebleeds? Do minor cuts bleed excessively?
  • Are stools bloody?
  • Have menstrual cycles been prolonged or heavy?
  • Does individual complain of headaches or dizziness?
  • On physical exam, were petechia or ecchymosis found?
  • Was the spleen enlarged on palpation?
  • Did individual have a CBC? Bone marrow biopsy? Coagulation studies?
  • Were other diseases such as HIV, ehrlichiosis, and SLE ruled out?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Does individual have mild to moderate thrombocytopenia? Is individual avoiding drugs that may affect the platelets?
  • Does individual/physician try to avoid injury or invasive procedures?
  • Is the underlying cause of the thrombocytopenia being treated?
  • Which type of thrombocytopenia does individual have? Is the treatment appropriate to the type?
  • Does individual respond appropriately to treatment?
  • Have platelet transfusions been necessary?
  • Has immune globulin been given?
  • Did splenectomy become necessary? Plasmapheresis?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect the ability to recover? Has life-threatening bleeding occurred? Has individual had multiple infections?

Source: Medical Disability Advisor



References

Cited

"Thrombotic Thrombocytopenic Purpura (TTP)–Like Illness Associated with Intravenous Opana ER Abuse — Tennessee, 2012." MMWR - Mortality and Morbidity Weekly Report. 11 Jan. 2013. Centers for Disease Control and Prevention. 15 Jul. 2015 <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6201a1.htm>.

Abrahamson, P. E. , et al. "The Incidence of Idiopathic Thrombocytopenic Purpura among Adults: A Population-Based Study and Literature Review." European Journal of Haematology 83 (2009): 83-89.

George, J. N. "How I Treat Patients with Thrombotic Thrombocytopenic Purpura: 2010." Blood 116 (2010): 4060-4069.

Kojouri, K. , et al. "Splenectomy for Adult Patients with Idiopathic Thrombocytopenic Purpura: A Systematic Review to Assess Long-Term Platelet Count Responses, Prediction of Response, and Surgical Complications." Blood 104 2623-2624.

Segal, J. B. , N. R. Powe, and . "Prevalence of Immune Thrombocytopenia: Analyses of Administrative Data." Journal of Thrombosis and Haemostasis 4 11 (2006): 2377-2383. NIH. National Center for Biotechnology Information. 15 Jul. 2015 <http://www.ncbi.nlm.nih.gov/pubmed/16869934>.

Stasi, R., et al. "Long-Term Observation of 208 Adults with Chronic Idiopathic Thrombocytopenic Purpura." American Journal of Medicine 98 (1995): 436-442.

Watson, H. , S. Davidson, and D. Keeling. "Guidelines on the Diagnosis and Management of Heparin-Induced Thrombocytopenia: Second Edition." British Journal of Haematology 159 (2012): 528-540.

Source: Medical Disability Advisor






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