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.

Thrombophlebitis


Related Terms

  • Deep venous thrombosis
  • Nonpuerperal Milk-leg
  • Phlebitis
  • Phlegmasia Alba Dolens
  • Phlegmasia Cerulea
  • Phlegmasia Cerulea Dolens
  • Venous Thrombosis

Differential Diagnosis

Specialists

  • Hematologist
  • Internal Medicine Physician
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

The specific site, cause, and extent of the blockage, the treatment necessary to relieve the condition, individual response to treatment, concurrent medical conditions, the age and general health of the individual, the ability to ambulate, and the development of complications, may influence the duration of disability.

Medical Codes

ICD-9-CM:
451.0 - Phlebitis and Thrombophlebitis of Superficial Veins of Lower Extremities
451.11 - Phlebitis and Thrombophlebitis, Femoral Vein (Deep) (Superficial)
451.19 - Phlebitis and Thrombophlebitis, Other; Femoropopliteal Vein; Popliteal Vein; Tibial Vein
451.2 - Phlebitis and Thrombophlebitis, Of Lower Extremities, Unspecified
451.81 - Phlebitis and Thrombophlebitis, Iliac Vein
451.82 - Phlebitis and Thrombophlebitis of Superficial Veins of Upper Extremities
451.83 - Phlebitis and Thrombophlebitis of Deep Vessels of the Upper Extremities
451.84 - Phlebitis and Thrombophlebitis of Upper Extremities, Unspecified
451.89 - Phlebitis and Thrombophlebitis, Other Site
451.9 - Phlebitis and Thrombophlebitis, of Unspecified Site

Overview

Thrombophlebitis is an inflammation of a vein (phlebitis) accompanied by an increased tendency to form blood clots (hypercoagulability), which leads to the formation of a blood clot (thrombus) in the vein. It can develop spontaneously or can be a complication of an injury, a disease, or a medical or surgical treatment.

Thrombophlebitis can be separated into two main categories depending on the depth of the vessels containing the blood clots: those that occur in veins just below the surface of the skin (superficial thrombophlebitis) and those that occur in a deep vein that usually accompanies an artery (deep venous thrombosis [DVT]). Although both conditions stem from the same causes and involve a similar physiologic process, superficial vein thrombophlebitis usually is not life threatening, while DVT is associated with high morbidity and mortality. (See separate entry for Deep Vein Thrombosis for more specific information). Migratory thrombophlebitis that passes from one leg to the other is associated with pancreatic and lung cancer, and the diagnostic process must focus on finding a possible malignancy. Septic thrombophlebitis is another serious form of the condition accompanied by infection and life-threatening coagulation abnormalities.

Thrombus formation is part of the normal coagulation of blood that helps prevent bleeding when blood vessels are penetrated or injured. However, if blood does not move through a vessel as quickly as it should (venous stasis) or a vessel is injured in some way, an inflammatory response begins in the blood vessel, and thrombus (clot) formation may follow. In superficial thrombophlebitis, the inflammatory response is followed immediately by platelet aggregation at the site of the injury, the first step in clot formation. A common example is clot formation at the insertion site of an intravenous (IV) line or as a result of trauma to the vein. Platelet aggregation in this type of thrombophlebitis usually can be decreased with anti-inflammatory medications. The treatment goal is to prevent superficial phlebitis from progressing, and thus affecting deeper veins and causing damage that can lead to chronic blood flow problems in the deep veins (deep vein insufficiency, sometimes referred to as postphlebitic syndrome).

Deep vein thrombosis (DVT) develops as a result of three conditions referred to as the Virchow triad: the absence of normal blood flow in a vein (venous stasis or venostasis), injury to the vein, and a state of hypercoagulability. A thrombus is most likely to form in the larger veins in the lower extremities (lower leg and thigh). This thrombus may interfere with circulation in the legs, and the clot may break off and travel through the bloodstream (embolize). The migrating thrombus (embolus) can pass through the bloodstream to the heart, and then lodge in an artery of the lungs (pulmonary embolism), reducing the flow of blood and oxygen availability and causing shortness of breath and chest pain. Pulmonary embolism is the most frequent and serious complication of DVT. In individuals with an atrial septal defect (patent foramen ovale) or a ventricular septal defect, an embolus of venous origin can pass through the septal defect from the right side to the left side of the heart, and cause a brain embolism (stroke) called a paradoxical embolism. DVT requires prompt treatment with anticoagulant medications and sometimes requires surgery.

Incidence and Prevalence: In hospitalized individuals, the incidence of venous thrombosis varies considerably, from 20% to 80%, and the incidence of DVT is estimated to be about 80 cases per 100,000 population annually (Schreiber). Superficial thrombophlebitis is very common in the US population, but frequency is not known precisely because many cases go unreported and untreated. DVT frequency also is not known precisely because of misdiagnoses; nevertheless, DVT and related pulmonary embolism are the leading preventable cause of death in hospitalized individuals, and about 600,000 individuals are hospitalized each year for DVT (Schreiber).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Although age is not an independent risk factor, other risk factors that increase with age place individuals over 40 years of age at greater risk for developing superficial thrombophlebitis and DVT. The male/female ratio for DVT is 1.2:1 indicating a slightly higher risk for men (Schreiber).

Risk factors for superficial thrombophlebitis include an increased blood clotting tendency, infection in or near a vein, current or recent pregnancy, varicose veins, and chemical irritation, or other local irritation or trauma. Prolonged sitting, standing, or immobilization such as bed rest at home or during hospitalization may also increase the risk. Superficial thrombophlebitis may occasionally be associated with abdominal cancers (e.g., carcinoma of the pancreas), DVT, inflammation, and clotting of small and medium arteries (Buerger's disease, also called thromboangiitis obliterans), and (rarely) with pulmonary embolism.

Risks for DVT include prolonged sitting, bed rest, or immobilization; recent surgery or trauma, especially hip surgery, gynecologic surgery, heart surgery, or fractures; childbirth within the last 6 months; obesity; smoking; and the use of medications such as estrogen and birth control pills. Other risks include a history of malignant tumor, polycythemia vera, changes in the levels of blood clotting factors increasing tendency to clot (hypercoagulability), mutations in the genes for certain clotting factors, disseminated intravascular coagulation (DIC), and dysfibrinogenemia.

Source: Medical Disability Advisor



Diagnosis

History: Many individuals are asymptomatic. Those with symptoms may report leg pain, leg swelling (edema), and in superficial thrombophlebitis tender, warm skin over the area of the thrombosis. Redness (erythema) may appear along a superficial vein. Individuals also may report a history of recent surgery, prolonged periods of bed rest, inactivity (e.g., prolonged airplane or auto travel), trauma, varicose veins, and a previous clotting disorder (hypercoagulability) or DVT. A family history of thrombosed veins and / or pulmonary embolism may also be described.

Physical exam: Skin signs may be visible and noticeable to the touch (palpable). The area above the superficial vein thrombosis may appear red and feel warm with a hard, cord-like mass apparent beneath the skin, which can be confirmatory. The area is extremely sensitive to pressure; the individual will feel pain during palpation or compression of the affected area. Superficial vein thrombophlebitis cannot be diagnosed solely on the basis of the physical examination if a thrombosed vein is not palpable, since erythema, edema, and pain are common to many other conditions (e.g., obstruction, venous reflux, cardiac problems, renal failure, infection, or trauma). In cases of suspected DVT there may be swelling, and palpation over the veins in the groin, behind the knee (popliteal) or inside the thigh may reveal tenderness (about 75% of individuals), and pain (about 50% of individuals) (Schreiber). Some individuals will have calf pain when the foot is passively moved upwards into dorsiflexion (Homan's sign); however, this is an unreliable finding (less than 33% of patients with confirmed DVT, but found in more than 50% of patients without DVT). A bluish discoloration of the entire lower leg when the collateral outflow veins are thrombosed (phlegmasia cerulea dolens) may be noted in DVT or painful white edema (phlegmasia alba dolens) and the absence of pulses. However, DVT is difficult to diagnose on the basis of signs and symptoms alone.

Tests: No diagnostic procedures are generally needed for superficial thrombophlebitis unless an individual has a history of coagulation disorders or previous DVT. An erythrocyte sedimentation rate (ESR) and C-reactive protein may be done to determine if inflammation is present. A complete blood count (CBC) and peripheral smear may help to rule out infection as a cause of symptoms. Frequent checks of pulse, blood pressure, temperature, skin condition, and circulation usually are done in a hospitalized patient.

When DVT is suspected, a number of diagnostic procedures may be performed in order to rule out arterial occlusive disease, inflammation of a lymphatic channel (lymphangitis), infection of the subcutaneous tissue beneath the skin (cellulitis), and muscle inflammation (myositis). Tests may also confirm the site and extent of venous occlusion. Color-flow Doppler ultrasound may be used to diagnose blood clots in the leg veins. Plethysmography, which measures changes in blood volume in the extremities, also may be used to evaluate the presence of venous obstruction. Less often, a venogram, an x-ray of the veins following dye injection, may be performed. As with color-flow Doppler ultrasound, this test can identify the location of venous obstruction in a limb. Rarely, magnetic resonance imaging (MRI) or computed tomography (CT) scan may be performed. D-dimer blood tests are performed to measure clot-related substances in the blood and serve as a rapid screening test for DVT. A high sensitivity D-Dimer test that is negative is good evidence that DVT is not present.

If migratory thrombophlebitis is present, diagnostic testing must include a workup for possible malignancy. CT angiography of the chest may be done if pulmonary embolism is suspected as a complication of DVT.

For recurrent cases with no obvious explanation, blood testing for clotting factor mutations is performed (including Lupus anticoagulant, Factor V Leiden, protein S, protein C, and antithrombin III).

Source: Medical Disability Advisor



Treatment

The goals of treatment for with superficial thrombophlebitis are to increase comfort and to prevent progression to DVT. Non-steroidal anti-inflammatory drugs (NSAIDs) usually will reverse the inflammation characteristic of superficial thrombophlebitis and help relieve pain. Anticoagulants (e.g., warfarin) may be used to prevent new clot formation. Thrombolytic therapy is used infrequently to dissolve an existing clot. Antibiotics may be used if an infection is present.

Compression stockings (thrombo-embolism deterrent [TED] hose) are routinely recommended and are able to reduces venous volume capacity by about 70%, increasing blood flow in deeper veins by a factor of 5 or more to reduce risk of DVT (Rosh). Compression also may be useful in helping to reduce pain in some cases. Moist heat may also be applied to decrease inflammation and pain of superficial thrombophlebitis. The affected limb may be elevated to reduce edema, to reduce pain by reducing pressure on the inflamed vein, and to reduce the risk of further damage. However, some physicians and recent research studies suggest that elevation of the leg and the immobility of bed rest promote venostasis, an important risk factor for DVT, and therefore continued ambulation may be recommended to limit venostasis and clot formation. Air travel, long car rides, and bed rest are not recommended for people with any type of phlebitis.

Surgical intervention including clot removal (thrombectomy), vein stripping, or vein bypass is rarely needed in superficial thrombophlebitis but may be considered if anticoagulant therapy is ineffective. A symptomatic, painful superficial vein may instead be punctured and a clot removed (puncture and evacuation) under local anesthesia, providing rapid relief. Thrombectomy is more often performed for DVT when anticoagulant therapy is ineffective or contraindicated.

DVT requires anticoagulant therapy as soon as possible after diagnosis is confirmed. Low-molecular-weight heparin (LMW heparin) is used immediately to prevent thrombus extension and often can reduce the risk of thrombus formation and embolus migration. It does not dissolve the existing clot, but prevents extension (growth) of the clot, and prevents recurrence of thrombosis. It is often given simultaneously with the initiation of warfarin therapy to reverse the hypercoagulability until warfarin has had the time necessary to control the hypercoagulability. Individuals with recurrent venous thrombosis or risk factors that are not correctable (e.g., prior DVT, clotting factor mutations, or advanced stage cancer) may be candidates for longer-term anticoagulation.

Thrombolytic therapy may be given in those with DVT to dissolve the original clot and prevent pulmonary embolism. It does not prevent new clot formation and must be followed by oral anticoagulation therapy. A "bird cage" filter may be placed in the major vein in the abdomen (inferior vena cava) that carries blood from the lower body to the heart to prevent pulmonary embolism in an individual with DVT. The procedure involves giving local anesthesia, insertion of the cage-like filter (e.g., Greenfield filter) through the femoral artery in the groin, and threading it into place in the vena cava using fluoroscopy or ultrasound images to guide the placement.

Source: Medical Disability Advisor



Prognosis

The prognosis for superficial thrombophlebitis is generally favorable, as this usually responds to prompt medical treatment. Complete recovery usually occurs within a relatively short period with pharmacological or surgical intervention.

The prognosis for DVT, however, is more guarded. It can resolve completely without therapy, but in about 20% of cases progress to venous insufficiency, or embolization (Schreiber). Long-term complications of DVT include venous stasis induced skin ulceration and venous insufficiency in lower leg veins. Massive pulmonary embolism (PE) is a leading cause of death in hospitalized individuals, accounting for 300,000 deaths each year in the US (Schreiber).

Source: Medical Disability Advisor



Complications

The most common complication of superficial thrombophlebitis is progression to the deeper veins, with development of DVT, and increased risk of pulmonary embolism. Surgery, stroke, heart attack (myocardial infarction), paralysis, high blood pressure (hypertension), and infection are possible complications but occur less frequently. Venous ulceration and venous insufficiency of the lower leg are long-term complications of DVT. A serious, potentially fatal complication of DVT is a pulmonary embolism, wherein the blood clot or a piece of the clot dislodges from its site of origin and lodges in one of the pulmonary arteries of the lung. Hemorrhagic complications are possible and serious in patients receiving thrombolytic therapy and can include cerebral hemorrhage. Anticoagulant therapy may lead to blood clotting problems if the dose is inappropriate or if the individual has an allergy to the anticoagulant medications. There is also a risk of later recurrence of thrombophlebitis in the same area due to scarring of the veins.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work accommodations may include giving the individual an opportunity to elevate the affected area, and accommodating the need for postural positional changes (e.g., no prolonged standing or sitting). Individuals should avoid sustained periods of inactivity. In more serious cases, leave of absence may be necessary. Company policy on medication usage should be reviewed to determine if medication use is compatible with job safety and function. If an individual is receiving anticoagulant therapy, working with sharp objects or any risk of trauma may need to be avoided.

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 the signs and symptoms of superficial thrombophlebitis or deep vein thrombosis (DVT)? Has either diagnosis been confirmed by a combination of history (risk factors, symptoms), physical exam (signs), and diagnostic tests?
  • Did individual have an IV inserted, recent surgery, recent infection, or experience trauma to the vein?
  • Are any risk factors for superficial thrombophlebitis present such as an increased blood clotting tendency, infection in or near a vein, current or recent pregnancy, varicose veins, blood clots, chemical irritation, other local irritation of the area, prolonged sitting, standing, or immobilization?
  • Does individual have any risk factors for DVT such as prolonged sitting, bed rest, or immobilization; recent surgery or trauma, especially hip surgery, gynecological surgery, heart surgery, or fractures; childbirth within the last 6 months; obesity; and the use of medications such as estrogen and birth control pills, a history of malignant tumor, polycythemia vera, hypercoagulability, or dysfibrinogenemia?
  • Does individual have cancer, DVT, or Buerger's disease? Does individual report leg pain, edema, and tender warm skin over the area of the thrombosis?
  • On physical exam for superficial thrombophlebitis, is the area red and warm with a hard, cord-like mass apparent beneath the skin? Was palpation painful?
  • On physical exam for a DVT, does individual have a positive Homan's sign? A blue or white appearance to the leg?
  • Were color-flow Doppler, blood coagulation studies, D-dimer assay, plethysmography done?
  • Were conditions with similar symptoms ruled out?
  • Is there any indication of septic thrombophlebitis?
  • Is there any indication of migratory thrombophlebitis? Has a malignancy workup been done to rule out pancreatic or lung cancer?

Regarding treatment:

  • Is individual being treated with analgesics, NSAIDs, anticoagulants, or thrombolytics? Is antibiotic therapy necessary?
  • Does individual wear TED hose? Use moist heat?
  • Was surgical intervention necessary? Was a filter inserted in the vena cava to prevent pulmonary embolism?
  • Was individual instructed to continue ambulation?
  • Is individual a candidate for long-term use of anticoagulant therapy?

Regarding prognosis:

  • Can individual’s employer accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Have any complications developed, such as stroke, myocardial infarction, paralysis, hypertension, infection, or pulmonary embolism that may affect recovery and length of disability?
  • Have any complications developed from medications such as hemorrhage from thrombolytic agents or coagulation disorders from anticoagulation therapy?
  • Is individual at risk for developing DVT? Pulmonary embolism? Recurrent thrombosis?

Source: Medical Disability Advisor



References

Cited

Rosh, Adam J. "Thrombophlebitis, Superficial." eMedicine. Eds. Samuel M. Keim, et al. 11 Aug. 2009. Medscape. 28 Sep. 2009 <http://emedicine.medscape.com/article/760563-overview>.

Schreiber, Donald. "Deep Venous Thrombosis and Thrombophlebitis." eMedicine. Eds. Francis Counselman, et al. 5 Aug. 2009. Medscape. 28 Sep. 2009 <http://emedicine.medscape.com/article/758140-overview>.

Source: Medical Disability Advisor






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