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.

Toxic Shock Syndrome


Related Terms

  • Menstrual Toxic Syndrome
  • Staphylococcal Toxic Shock Syndrome
  • Streptococcal Toxic Shock Syndrome
  • TSS

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Critical Care Internist
  • Emergency Medicine Physician
  • Family Physician
  • General Surgeon
  • Gynecologist
  • Infectious Disease Internist
  • Nephrologist
  • Neurologist

Comorbid Conditions

Factors Influencing Duration

Duration depends on the severity of symptoms, the individual's response to treatment, and any complications. Most individuals recover from TSS in 2 to 3 weeks. For jobs that require physical strength, disability may be longer due to muscle weakness or heart damage. Jobs that require great amounts of mental concentration may also require longer disability.

The length of disability may be extended if surgery is necessary to remove gangrenous or infected tissue. Extensive damage to the heart, lungs, and kidneys may also necessitate a longer disability period.

Medical Codes

ICD-9-CM:
040.82 - Bacterial Diseases, Specific, Other; Toxic Shock Syndrome

Overview

Toxic shock syndrome (TSS) is a serious but rare, life-threatening disease caused by exotoxins produced by certain strains of staphylococcal (Staphylococcus aureus) or streptococcal (Streptococcus pyogenes) bacteria. These toxins affect the entire body by causing shock (i.e., the body is unable to move enough blood to all the tissues and organs). Shock typically occurs in three stages that may progress rapidly over a 24- to 72-hour period. During the first stage, symptoms are minimal while the body attempts to compensate for the changes taking place. The second stage progresses more rapidly because the body is no longer able to compensate for the changes; blood flow decreases to many organs, damaging them. The third stage is usually irreversible, since the heart is so extensively damaged that it cannot pump blood through the body; organ function becomes compromised, and death may result.

Reported cases of staphylococcal TSS peaked in 1979 and 1980 and were mainly associated with the use of ultra-absorbent tampons by menstruating women. Since these tampons have been withdrawn from the market, menstrual-associated cases of TSS have declined.

TSS in women is associated with pre-existing vaginal colonization by staphylococcus coupled with the prolonged use of high-absorbency tampons, menstrual sponges, diaphragms, and cervical caps that tend to trap bacteria and cause infection. Cases have also been reported following childbirth, possibly from trauma to the vaginal tissues. Toxic shock syndrome can also occur in men or women as a result of infection of wounds, insect bites, burns, bones, surgical wounds, or respiratory infections. TSS caused by group A streptococcal bacteria has a substantially higher death (20-60%) and complication rate than TSS caused by staphylococcal bacteria (< 3%).

Incidence and Prevalence: Incidence of invasive group A Streptococcus infection is estimated in 1.5-5.2 cases per 100,000 people annually; about 8-14% of these individuals also develop TSS. The incidence of staphylococcal TSS in menstruating women is estimated at 1 per 100,000 women (Venkataraman).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Only women of childbearing age contract menstrual-related TSS, but men and women of all races are equally at risk for TSS associated with surgical wounds, bites, burns, and similar breaks in the skin. Risk related to age is not clear; some studies find equal risk at all ages, whereas others find increased risk in individuals over age 60 with underlying medical problems (Venkataraman). Recent infection with chicken pox (varicella) increases the risk of developing TSS.

Source: Medical Disability Advisor



Diagnosis

History: An individual with TSS presents with a sudden onset of high fever, vomiting, and watery diarrhea. These symptoms are usually accompanied by a sore throat (pharyngitis), abdominal pain, vomiting, diarrhea, muscle pain (myalgia), joint pain (arthralgia), lightheadedness, headache, confusion, and fainting (syncope). A skin rash, inflammation of the mucus membranes of the eye (conjunctivitis), and extreme thirst may also occur. The individual may lose consciousness and depend on a family member or friend to communicate the history and symptoms. The individual may also have had a recent infection. Confusion is more common with staphylococcal TSS. Severe pain at the site of infection is the most common symptom of streptococcal TSS.

Physical exam: The exam may reveal fever higher than 102° F (38.9° C) and low blood pressure (hypotension) accompanied by abnormalities (dysfunction) in three or more organ systems (kidney, liver, heart, lungs, gastrointestinal, muscular, neurological, or hematological). Other findings may include red throat; swelling of the hands, feet, and ankles; and signs of wound or vaginal infections. An erythematous rash may first appear on the trunk, then spread to the arms and legs, and eventually involve the palms and soles; the skin begins to flake off 1 to 2 weeks later.

Tests: Laboratory blood tests reveal an abundance of abnormalities, possibly including increased white blood cells (leukocytosis), decreased platelets (thrombocytopenia), decreased red blood cells (anemia), abnormal liver or kidney chemistries or electrolytes, abnormal blood clotting tests, urinalysis positive for bacteria, myoglobin or blood, and positive bacterial cultures of wound pus or vaginal fluid. Blood cultures are usually negative in staphylococcal TSS, since the disease is caused by the toxins produced rather than by the infection itself. Blood cultures are positive, however, in about 60% of the individuals with streptococcal TSS (Venkataraman).

The rapid streptococcal test can be done in 10 to 15 minutes and is positive in more than 85% of individuals with TSS caused by Streptococcus. In most situations, emergency treatment is started before laboratory results are available. Blood tests for viral infections and rheumatologic conditions should be negative. Electrocardiogram may be abnormal if the heart is involved.

Source: Medical Disability Advisor



Treatment

Treatment begins immediately and usually involves rapid administration of fluids through an IV line; oxygen; heart monitoring; antibiotics; cleaning, scraping (debridement), draining of the infected area; and removal of the source of the toxin (such as a tampon). In some cases, pooled human immunoglobulin is given. Kidney, respiratory, or heart complications must be treated promptly. Surgical consultation may be needed for debridement, drainage, or amputation of a clearly infected area. Individuals with kidney failure need dialysis.

Source: Medical Disability Advisor



Prognosis

With proper treatment, most individuals may fully recover in 2 to 3 weeks, but in streptococcal TSS, death can occur in up to 30% to 70% of cases; mortality in staphylococcal TSS has declined to 1.8% (Venkataraman). If shock proceeds to its third stage, all organ systems rapidly deteriorate. Immediate, aggressive treatment yields the most favorable results.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation therapy depends on any complications that occur from TSS. Because the organ most susceptible to damage during shock is the heart, a physical therapist may develop an exercise program for strengthening the heart and lungs. Toxic shock syndrome also warrants rehabilitation if the condition results in general weakness and/or affects the nervous system. Once a physician determines no contraindications for physical activity, a gradual strengthening program is initiated by the rehabilitation professional. Aerobic-type activities focus on increasing the individual's ability to work and resistance to fatigue. In the case of damage to the nervous system, issues of balance and retraining are addressed by the physical therapist.

As endurance increases without symptoms of shortness of breath, the individual can begin active light resistance training, progressing to moderate resistance exercises using free weights and/or weight machines. The frequency of the program will vary, depending on the individual's general health. If tolerated, the individual performs strengthening exercises 3 times a week and aerobic activities on the nonstrengthening days.

Balance exercises will help addressing any loss of coordination that may result from TSS. Balance rehabilitation varies for individuals. The intensity and progression of exercises depends on the effect they have on the body, especially the kidneys, and the individual's overall health.

Source: Medical Disability Advisor



Complications

Lack of blood flow can damage any organ in the body. It can cause acute kidney failure, brain damage, lung problems, heart damage with cardiac dysrhythmia, or loss of a limb. Other complications include electrolyte and acid-base imbalance, and bacteremia. Release of bacterial toxins into the bloodstream may cause abnormalities in blood clotting that lead to a loss of blood supply to different parts of the body (disseminated intravascular coagulation). Lung problems may lead to extreme difficulty in breathing (acute respiratory distress syndrome [ARDS]). In severe cases, death may result.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Extended periods of weakness may prevent heavy physical work. Some mental confusion may persist for a few weeks and may diminish performance in high-stress situations. Other accommodations depend on the severity of organ damage, if any. With complete recovery, work restrictions should be minimal.

Risk: Because toxic shock syndrome is not transmitted between individuals, there is no risk to coworkers. Risk may be heightened in women of menstruating age who work in jobs without regular bathroom access, as this promotes the practice of needing to use ultra absorbent tampons while at work.

Capacity: Capacity is affected by the type and severity of the TSS, the stage of infection upon initiation of treatment, and whether organ damage occurs. Most individuals will be able to return to previous job duties upon successful resolution of the infection. During active treatment, the individual will be hospitalized and unable to work.

Tolerance: Tolerance may be temporarily reduced upon return to work secondary to fatigue and deconditioning. Encouraging progressive general exercise may be of help.

Accommodations: Employers willing to accommodate activities as needed can have employees return to work sooner.

Source: Medical Disability Advisor



Maximum Medical Improvement

30 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:

  • If individual is female, does she have a history of using high-absorbency tampons, menstrual sponges, diaphragms, or cervical caps? Has she given birth recently?
  • Is there a history of wound infection, insect bite, burns, recent surgery, or respiratory infection?
  • Does individual have a fever higher than 102° F (38.9° C) and hypotension?
  • Does individual complain of vomiting and watery diarrhea?
  • Was the throat reddened and sore (pharyngitis)?
  • Were there complaints of myalgia or arthralgia? Are feet and ankles swollen?
  • Did individual experience lightheadedness, headache, or syncope?
  • Was there a skin rash, conjunctivitis, or extreme thirst?
  • Was individual confused? Complaining of pain? If so, where was the pain located?
  • Did the blood reveal infection, decreased clotting ability, and/or anemia?
  • Were liver and kidney functions affected?
  • Did urinalysis reveal blood, myoglobin, or bacteria?
  • Was a throat culture done? Did it reveal a streptococcal infection?
  • Were blood cultures negative, suggesting staphylococcal TSS, or were they positive, suggesting streptococcal TSS?
  • What organisms, if any, did wound or vaginal cultures reveal?

Regarding treatment:

  • Was treatment received quickly?
  • Did individual receive intravenous fluids and antibiotic therapy? Was the source of the toxin removed?
  • How did individual respond to treatment?
  • Did individual receive surgical consultation? If so, was surgical intervention warranted?
  • Has there been kidney, lung, or heart involvement? If so, was consultation from appropriate specialists received (nephrologist, pulmonologist, cardiologist)? Was the damage to the organ(s) temporary and reversible or permanent and irreversible?

Regarding prognosis:

  • Did adequate time elapse for recovery (2 to 3 weeks)?
  • Based on the type of infection, what was the expected outcome?
  • Did individual experience any complications, such as organ dysfunction, gangrene, or coagulopathy that could affect recovery and prognosis?
  • Was surgical amputation of a limb performed to treat gangrene?
  • Would individual benefit from psychiatric counseling to recover from the trauma of the illness?

Source: Medical Disability Advisor



References

Cited

Venkataraman, Ramesh, and Sat Sharma. "Toxic Shock Syndrome." eMedicine. 16 Apr. 2015. Medscape. 20 Jul. 2015 <http://emedicine.medscape.com/article/169177-overview#showall>.

Source: Medical Disability Advisor






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