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.

Tics


Related Terms

  • Chronic Motor Tic Disorder
  • Chronic Vocal Tic Disorder
  • Habit Spasm
  • Tic Disorder
  • Transient Tic Disorder

Differential Diagnosis

  • Akathisia
  • Athetoid movements
  • Autism
  • Carbon monoxide toxicity
  • Chorea gravidarum
  • Chorea in adults
  • Chorea in children
  • Chronic motor or vocal tic disorder
  • Cocaine
  • Complex partial seizures
  • Drug-induced tardive dyskinesia
  • Dystonias
  • Encephalitis lethargica
  • Essential myoclonus
  • Frontal lobe syndromes
  • Hallervorden-Spatz disease
  • Hemiballistic movements
  • Hemifacial spasm
  • Huntington disease
  • Hyperekplexia and other startle syndromes
  • Inherited metabolic disorders
  • Mannerisms
  • Medication-induced movement disorder not otherwise specified
  • Mental retardation
  • Monoamine oxidase a deficiency
  • Movement disorders in individuals with developmental disabilities
  • Myoclonus
  • Neuroacanthocytosis
  • Neuronal ceroid lipofuscinosis
  • Neurosyphilis
  • Obsessive-compulsive disorder (OCD)
  • Paroxysmal dyskinesia
  • Periodic limb movement disorder
  • Restless legs syndrome
  • Rett syndrome
  • Schizophrenia
  • Seizures
  • Spasm
  • Stereotypic movement disorder
  • Stimulants
  • Stroke (infarction)
  • Synkinesis
  • Tardive dyskinesia
  • Tic disorder not otherwise specified
  • Tic douloureux
  • Transient tic disorder
  • Tremor
  • Tuberous sclerosis
  • Wilson's disease

Specialists

  • Clinical Psychologist
  • Neurologist
  • Occupational Therapist
  • Psychiatrist

Comorbid Conditions

  • ADHD
  • Impulsivity
  • Motor hyperactivity
  • Neurologic conditions
  • Obsessive-compulsive disorder
  • Orthopedic problems
  • Skin conditions
  • Substance abuse

Factors Influencing Duration

The severity of the disorder, effectiveness of treatment, and interference with job requirements influence the length of disability. Medication used to treat tics or ADHD can have side effects that may lengthen disability.

Medical Codes

ICD-9-CM:
307.20 - Special Symptoms or Syndromes, Not Elsewhere Classified; Tic Disorder, Unspecified
307.22 - Special Symptoms or Syndromes, Not Elsewhere Classified; Chronic Motor or Vocal Tic Disorder
307.23 - Special Symptoms or Syndromes, Not Elsewhere Classified; Gilles De La Tourettes Disorder; Motor-verbal Tic Disorder

Overview

The section about tic disorders in the DSM-IV-TR includes Tourette's disorder, chronic motor or vocal tic disorder, transient tic disorder, and tic disorder not otherwise specified (DSM-IV-TR); in the DSM-5 it includes Tourette's disorder, persistent (chronic) motor or vocal tic disorder, and provisional tic disorder (DSM-5).

A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization that may be simple and involve only a few muscle groups or complex and involve multiple muscle groups. Many individuals report a sensation of rising tension or a sensation in a part of the body that precedes the motor or vocal tic, and a feeling of relief or tension reduction following the involuntary movement. Although tics are experienced as irresistible, they can be suppressed for varying lengths of time. An individual may feel the need to perform a complex tic until tension is relieved.

Tics occur in bouts of varying frequencies, generally decrease or disappear during sleep, and can change in location, number, frequency, and duration over time. The movements may be simple and resemble shock-like contractions of muscles or muscle groups (myoclonic jerks).

Incidence and Prevalence: Due to the lack of a precise definition of Tourette's disorder, the exact prevalence is not known, though a prevalence of 0.7% is suggested. Up to 4.2% of all children have some type of tic disorder. The prevalence of a lifetime diagnosis of Tourette's disorder estimated by the Centers for Disease Control and Prevention (CDC) is 3 cases per 1,000 population (Robertson).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Tics often develop in childhood but also appear in adulthood. Vulnerability to tic disorders is transmitted within families and appears genetic. The specific gene(s) involved are those that affect the ability of the brain to break down chemicals (neurotransmitters) used by nerve cells to communicate with each other, especially the neurotransmitters dopamine, serotonin, and norepinephrine. Not everyone who inherits the genetic vulnerability expresses symptoms. The precise type or severity of tic may be different from one generation to another and can be modified by nongenetic factors. In some cases, tics may follow strep throat, which suggests that autoimmune factors may be involved.

Tics may occur alone or as part of Tourette's syndrome, an inherited neurological disorder characterized by tics and often associated with attention-deficit/hyperactivity disorder (ADHD) or with obsessive-compulsive disorder (OCD). The symptoms of Tourette's syndrome usually appear before age 18.

Source: Medical Disability Advisor



Diagnosis

History: Based on criteria listed in the DSM-IV-TR, individuals with Tourette's disorder have both multiple motor tics and one or more vocal tics that have been present at some point in the course of the illness, although not necessarily at the same time. The tics appear many times a day (usually in bouts) almost daily or intermittently for more than 1 year, and during this time there is never a period of more than 3 months in a row without tics. The onset of the disorder occurs before age 18. The disturbance is not a consequence of the direct physiological effects of a substance (stimulants) or a general medical condition (Huntington's disease or postviral encephalitis) (DSM-IV-TR).

Individuals with chronic motor or vocal tic disorder have had single or multiple motor or vocal tics at some time during the illness. The tics occur many times a day almost daily or intermittently during more than 1 year, and during this period there are never more than 3 consecutive months without tics. The disorder begins before age 18. The disorder is not secondary to the direct physiological effects of a substance (stimulants) or a general medical condition (Huntington's disease or postviral encephalitis). Finally, criteria have never been met for Tourette's disorder (DSM-IV-TR).

Individuals with transient tic disorder have single or multiple motor and/or vocal tics. The tics occur many times a day, almost daily for at least 1 month, but for no longer than 1 year. The disorder begins before age 18. The disorder is not secondary to the direct physiological effects of a substance (stimulants) or a general medical condition (Huntington's disease or postviral encephalitis). Finally, criteria have never been met for Tourette's disorder or chronic motor or vocal tic disorder. It is necessary to specify if the episode is single or recurrent (DSM-IV-TR).

The category of tic disorder not otherwise specified includes disorders characterized by tics that do not meet criteria for a specific tic disorder, for example, tics that occur for less than 4 weeks or with an onset after age 18 (DSM-IV-TR).

According to the criteria listed in the DSM-5, individuals with Tourette's disorder have both multiple motor tics and one or more vocal tics that have been present at some point in the course of the illness, although not necessarily at the same time. The frequency of the tics may increase or decrease, but have persisted for more than 1 year. The disorder comes on before age 18. The disturbance is not a consequence of the direct physiological effects of a substance (e.g., cocaine) or a general medical condition (Huntington's disease or postviral encephalitis) (DSM-5).

Individuals with persistent (chronic) motor or vocal tic disorder have had single or multiple motor or vocal tics during the illness. The frequency of the tics may increase or decrease, but have persisted for more than 1 year. The disorder begins before age 18. The disorder is not secondary to the direct physiological effects of a substance (e.g., cocaine) or a general medical condition (Huntington's disease or postviral encephalitis). Finally, criteria have never been met for Tourette's disorder (DSM-5).

Individuals with provisional tic disorder have single or multiple motor and/or vocal tics. The tics have been present for less than 12 months, and the disorder begins before age 18. The disorder is not secondary to the physiological effects of a substance (e.g., cocaine) or another medical condition (Huntington’s disease, postviral encephalitis). Finally, criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder (DSM-5).

Physical exam: The exam includes observing involuntary movements. Simple tics may include shaking the head, blinking, sniffing, or waving the arms. Complex tics may include touching parts of the body, assuming and holding unusual positions, twisting hair, or making obscene gestures. Vocal tics may also be present, such as barking, clearing one’s throat, squealing, repetition of one's own sounds (palilalia) or the sounds of others (echolalia), and explosive, involuntary cursing (coprolalia).

Tests: Tests may include magnetic resonance imaging (MRI) or computed tomography (CT) of the head, electroencephalogram (EEG), or blood tests to rule out other conditions possibly confused with tics. However, diagnosis of tics or Tourette's disorder is based primarily on history and observation of abnormal movements. Single-photon emission computed tomography (SPECT) brain scan is a research tool that can show abnormal blood flow in the caudate nucleus, a part of the brain involved in controlling movement. Serum ceruloplasmin and/or slit-lamp examination for Kayser-Fleischer rings can be useful to rule out Wilson's disease as a possible etiology of tics.

Source: Medical Disability Advisor



Treatment

When tics are mild and not socially disabling, no treatment is required. A drug useful for all individuals with Tourette’s disorder is not available, no drug eliminates all the symptoms, and the drugs commonly used may have serious side effects. Antipsychotic drugs (also known as neuroleptics or dopamine antagonists) such as risperidone or haloperidol in small doses help reduce the frequency and severity of tics, although both short- and long-term side effects may occur. Neuromuscular blockers, skeletal muscle relaxants, and benzodiazepines have all shown promise in controlling tics.

The blood pressure medication clonidine (a central alpha-adrenergic agonist) is more effective in reducing motor tics than vocal tics. Relief of nervous tension by sedative or tranquilizing drugs and psychotherapy may be helpful. If the individual also has OCD (common among those with tic disorders), cognitive behavioral therapy may be helpful. Group therapy could also be a useful and cost-effective way to provide cognitive behavioral treatment. Habit reversal therapy, which involves relaxation therapy and helping patients have a "competing response" to tic urges, causes a 75% drop in tic symptoms in half of the individuals treated (Robertson).

Source: Medical Disability Advisor



Prognosis

There is no cure for Tourette's disorder and it almost always persists throughout life, but many individuals with this condition show improvement when they get older (by age 18, about 50% of individuals are free of tics (Robertson)). However, associated neuropsychiatric disorders such as depression, panic attacks, mood swings, and antisocial behavior may increase the level of severity. The primary goal of treatment is not the complete elimination of tics but rather suppression of tics to the point at which the individual can function normally. Even without treatment, symptoms can go into remission and then recur, but with treatment, many individuals can experience a significant reduction in symptoms. There is a reduction in tic severity with antipsychotic medication (Robertson).

Source: Medical Disability Advisor



Complications

Stressful situations can aggravate tics. Those with Tourette's syndrome may also have OCD or ADHD (Robertson). Severe tics may lead to depression, social withdrawal, or accidental self-injury.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

To some extent concerns about gainful employment depend on what parts of the body are affected by the tic and what the job demands are. For example, if there were multiple sudden tics involving the hands, many jobs that require fine dexterity could be off-limits. One example is neurosurgery: a serious injury to the central nervous system caused by a tic-like movement on the part of the surgeon would not be easily reversible. Other jobs involving fine dexterity in which any particular error can be reversed by simply repeating the task to eliminate the error, such as typing, proofreading, and editing, could still be performed by individuals with tics.

Time-limited restrictions and work accommodations are necessary only infrequently, for the most serious cases. In these instances, time-limited restrictions and work accommodations should be determined based on the characteristics of the individual's response to the disorder, the functional requirements of the job and work environment, and the flexibility of the job and work site. Restrictions/accommodations are designed to help maintain the worker's capacity to remain at the workplace without a work disruption or to promote timely and safe transition back to full work productivity, while promoting safety for the individual, coworkers, and any member of the public that might be affected by the tic.

Risk: Depending on the type and severity of tic, it may not be safe for individuals with tics to drive, operate heavy machinery, or work at heights. Those with certain types of persistent complex motor or vocal tics (e.g., obscene gestures, coprolalia) may not be well-suited for interaction with the public.

Capacity: Capacity may be influenced by comorbid conditions (e.g., ADHD, OCD) that may affect the individual’s attention and concentration in the workplace. Individuals taking medication to control their symptoms may require periodic drug testing to ensure that substance abuse or addiction is not an issue.

Tolerance: Tolerance is typically not a concern with this diagnosis. Individuals who are motivated to work will generally find a way to do so, and will be compliant with treatments such as cognitive behavioral and relaxation therapies to help suppress their tics.

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 a diagnosis of tics confirmed?
  • Have conditions with similar symptoms been ruled out?
  • Does the individual have a coexisting condition that may affect recovery?
  • Do stressful situations aggravate tics?

Regarding treatment:

  • Would antipsychotic or other medication be beneficial? If not effective, should dosage be modified? Do side effects prevent individual from using or benefiting from that particular medication?
  • Does the individual also have ADHD or OCD?
  • Would the individual benefit from more frequent cognitive behavioral encounters or the addition of group therapy?

Regarding prognosis:

  • Do symptoms persist despite treatment?
  • Are coexisting disorders being effectively addressed?
  • Is the individual participating in appropriate cognitive behavioral or group therapy?
  • Would the individual benefit from evaluation by a neurologist?
  • Can the individual continue in present position under appropriate work modifications and accommodations?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Robertson, William C. "Tourette Syndrome and Other Tic Disorders." eMedicine. 20 Apr. 2014. Medscape. 20 Jul. 2015 <http://emedicine.medscape.com/article/1182258-overview#showall>.

Source: Medical Disability Advisor






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