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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.

Transient Ischemic Attack


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
435.0 - Basilar Artery Syndrome
435.1 - Vertebral Artery Syndrome
435.2 - Subclavian Steal Syndrome
435.3 - Vertebrobasilar Artery Syndrome
435.9 - Unspecified Transient Cerebral Ischemia; Impending Cerebrovascular Accident; Intermittent Cerebral Ischemia; Transient Ischemic Attack [TIA]

Related Terms

  • Intermittent Cerebral Ischemia
  • Mini-stroke
  • TIA
  • Transient Cerebral Ischemia

Overview

Transient ischemic attack (TIA) refers to a temporary loss of blood supply (ischemia) and oxygen delivery (hypoxia) to a part of the brain. TIA usually is due to blockage of an artery between the heart and the brain, such as the carotid or vertebral arteries in the neck, or within the brain itself, resulting in a sudden decrease in brain functions (neurologic deficit) that may last from less than 1 hour to several hours. Symptoms lasting up to 24 hours may signal stroke rather than TIA; results of neuroimaging suggest that many TIAs are actually minor strokes (Zhao). After a TIA, normal functions resume. Symptoms vary with the area of the brain affected. Even a brief interruption of blood flow can cause a decrease in brain function in a specific part of the brain but, unlike stroke, a TIA causes no permanent damage (infarction) to the brain.

Symptoms associated with TIA are similar to those associated with a stroke (e.g., numbness in the face or limbs, confusion, difficulty speaking, vision disturbances, dizziness, difficulty maintaining balance, and severe headache), except that they disappear completely within a relatively short time.

Typically, alternative (collateral) circulation routes are sufficient to overcome narrow or even blocked arteries. However, as plaque deposits continue to build, these safety factors may become overwhelmed. A TIA is a serious warning of increased risk for stroke, and requires immediate medical evaluation and possible treatment to prevent blood clot formation and reduce the likelihood of stroke.

Incidence and Prevalence: Every year, approximately 240,000 Americans are diagnosed with TIA (Kleindorfer). In individuals younger than age 35 incidence is 1 to 3 per 100,000 and over age 85 incidence is 600 to1500 per 100,000 (Kleindorfer). About 15% of individuals who are diagnosed with TIA will have a stroke within 6 months (Kleindorfer).

Source: Medical Disability Advisor



Causation and Known Risk Factors

A family history of stroke and certain lifestyle choices, (e.g., smoking, heavy alcohol use) increase risk of TIA. The age at onset varies, but incidence increases with age. TIAs are significantly more common in men (101 per 100,000) than women (70 per 100,000); incidence among blacks is 98 per 100,000 and among whites is 81 per 100,000 (Kleindorfer). Risk is greater for individuals with diabetes, heart disease, coronary artery disease, hypertension, migraine headaches, sedentarism, dyslipidemia, and obesity (von Sarnowski).

TIAs typically are associated with high blood pressure (hypertension) and atherosclerosis, a disease in which fatty deposits (atheromatous plaque) build up along the interior walls of arteries. Plaque deposits may become large enough to temporarily block blood flow, or may promote the formation of blood clots (thrombi) that may then occlude that artery or may become dislodged (embolism), occluding an artery downstream. Less common causes of TIA include blood disorders (e.g., sickle cell disease, polycythemia, hyperviscosity syndromes), spasms of small arteries in the brain, blood vessel abnormalities (e.g., fibromuscular dysplasia), inflammation of the arteries, systemic lupus erythematosus (SLE), and syphilis.

Source: Medical Disability Advisor



Diagnosis

History: History is important in diagnosing TIA, because the average duration is about 10 minutes, and symptoms usually last only a few hours. Often by the time an individual is examined by a physician, symptoms have resolved. Family, work colleagues, or emergency medical workers may be able to provide useful information about onset, duration, signs, symptoms, or previously undiagnosed episodes. Family history of migraine and atypical migraine also is important, as migraine may present with transient neurological deficits. A history of headache with and without associated symptoms may be significant. Specific symptoms vary depending on the location in the brain, degree of vessel involvement, and the extent of collateral circulation. Symptoms usually occur on the same side of the body if more than one body part is involved. A history of hypertension and/or cardiovascular disease may be reported. Obtaining a complete medical history, including recent surgery, prior TIA episodes, prior stroke, heart attack (myocardial infarction), seizures, infections, diabetes or other metabolic disease, use of recreational drugs, tobacco and alcohol use, and current medications, may assist with diagnosis.

Symptoms typically include a loss of sensation or motor skills, vision disturbances (e.g., loss of vision in one eye, decreased visual acuity, double vision), weakness, numbness, tingling in the arms (paresthesia), speech difficulty (garbled, slurred, or thick speech), vertigo, problems with balance, poor coordination, gait changes (staggering), falling, and an inability to think clearly or understand speech. Individuals may report episodes that only last a few minutes but occasionally continue for 1 to 2 hours. Episodes may recur or the individual may later experience a stroke, or in some cases, the individual may experience no further symptoms.

Physical exam: A complete physical with emphasis on the neurologic and cardiovascular systems is done when TIA is suspected. An individual may present with vague symptoms that may have already begun to subside. Hypertension may be found. Speech disturbances, visual changes, or weakness, numbness, loss of sensation or difficulty in moving the extremities on one side of the body may be noted. Less common are facial paralysis, eye pain, and confusion. Assessment of eye movements, pupillary reactivity, tongue and palatal movements, shoulder elevation as well as vision and hearing is done to evaluate the cranial nerves.

A complete neurological examination, including cranial nerve testing, somatic motor strength, and somatic sensory testing, may be abnormal during a TIA but normal afterwards. A complete neurological exam is crucial to rule out a residual effect from the TIA, which may be concurrent with a neurological deficit. Neurologic deficits may be noted using the National Institutes of Health Stroke Scale (NIHSS). Mental status can be evaluated in more detail with the standard Mini-Mental Status Examination; observation of individual's attentiveness, interaction with examiner, language use, memory skills, and hydration status, may indicate altered mental status.

Listening with a stethoscope (auscultation) over the carotid or other artery may reveal an abnormal sound (bruit) caused by irregular blood flow; this may indicate atherosclerotic plaque or a thrombus in the area. Signs of cardiovascular disease may be noted on auscultation of the heart, and examination of the chest may reveal evidence of cardiac disorders such as surgical scars or an implanted pacemaker or cardioverter defibrillator. Comorbidities such as active infection or a mass (e.g., tumor or subdural hematoma) may be observed.

Tests: An eye examination, including fundoscopy to identify retinal plaques and pigmentation, and a pressure (glaucoma) test, usually is done. A complete blood count (CBC) accompanied by coagulation tests such as prothrombin time (PT), partial thromboplastin time (PTT), and antithrombin III, factor V Leiden, protein C, and protein S are done to evaluate hematologic diseases and risk for thromboembolism. Serum chemistries, including a lipid profile, cardiac enzymes, and creatinine, may provide useful information. Additional testing may include syphilis serology, toxicology screening, hemoglobin electrophoresis, serum protein electrophoresis, and examination of spinal fluid. An electrocardiogram (ECG) and transthoracic or transesophageal echocardiography (TTE/TEE) may be done if a cardiovascular disorder such as atherosclerosis is suspected; an echocardiogram may also help uncover heart valve abnormalities or arrhythmias that encourage clot development. To confirm vessel blockage, ischemia, intracranial bleeding, tumor, or atherosclerosis, an individual may undergo diagnostic cranial magnetic resonance imaging (MRI) and head computed tomography (CT) scans, or cerebral angiography (magnetic resonance angiography [MRA] or CT angiography [CTA]). Vascular imaging, such as Doppler ultrasound of the carotids, may be performed. These procedures help to locate problem areas and aid in planning the course of treatment for the individual.

Brain imaging studies of patients with multiple TIAs may reveal localized atrophy. These may suggest that, although clinically the patient's symptoms have resolved, the individual may have had a stroke as defined by MRI results or have had recent past strokes that are responsible for brain lesions viewed in images.

Source: Medical Disability Advisor



Treatment

The goal of treatment is to improve the arterial blood supply to the brain and prevent development of stroke. Prompt evaluation within 60 minutes is necessary to identify the cause and determine appropriate treatment. This usually requires hospitalization. Because signs or symptoms are of short duration, individuals may ignore them. However, it is imperative that physicians are made aware of the condition and that the symptoms are addressed. Treatment of the underlying cause is essential.

Emergency treatment to reduce short- and long-term risk of stroke may include antihypertensive therapy if blood pressure exceeds 220/120mmHg, antithrombotic therapy if intracranial hemorrhage has been rule out, antiplatelet agents such as aspirin or dipyridamole, or anticoagulant therapy such as warfarin. Aspirin often is the antiplatelet drug of choice to reduce risk of clot formation. Similar medications may be prescribed for ongoing use after discharge to treat hypertension, atherosclerosis, and thrombosis and prevent a recurrence or progression of the condition.

Disorders such as heart disease, diabetes mellitus, and blood disorders are treated appropriately. If the carotid artery is involved, a procedure may be necessary to remove the blockage (carotid endarterectomy), or if blockage is severe, a vessel graft may be required. Lifestyle adjustments to reduce risk of stroke due to atherosclerosis may include losing weight, cessation of smoking, reducing or eliminating alcohol consumption, and adopting a low-fat, low-glycemic, high-fiber diet. Diabetics are treated to control blood glucose levels. Lipid control may include prescribing a statin agent.

Source: Medical Disability Advisor



Prognosis

TIAs are generally of short duration; symptoms generally disappear within 24 hours. TIAs, however, are predictors of impending stroke, and may require immediate medical intervention. The risk of stroke after experiencing a TIA is 4% at 2 days, 8% at 30 days, and 9% at 90 days; however, prospective day-to-day follow up has shown the 7-day incidence of stroke to be as high as 11% (Kleindorfer). Approximately 30%of individuals who experience a TIA will die within 5 years, 14% greater than expected (Gattellari).

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Cardiovascular Internist
  • Neurologist
  • Radiologist
  • Vascular Surgeon

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

The primary short-term complication of a TIA is a major stroke. Individuals may also injure themselves by falling during the TIA.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors that may influence the length of disability include the underlying chronic disease processes, the age of the individual at diagnosis, effectiveness of treatment, and whether surgery is indicated.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Given the temporary nature of the TIA episode, work restrictions usually are minimal. However, individuals who experience recurrent episodes may require work accommodations, particularly if they operate heavy machinery, work under difficult environmental conditions, work at unrestricted heights, or drive frequently. As such, work accommodations will require consideration on a case-by-case basis. Time off may be necessary to thoroughly evaluate the underlying reason for TIA.

Risk: A TIA would not be expected to have any job risk associated with it. Treatment of underlying risk factors would be important. If a heavy demand job leads to uncontrolled hypertension, consideration should be given to medication changes.

Capacity: A TIA would not be expected to have any impact on capacity.

Tolerance: A TIA would not be expected to have any impact on tolerance. Concerns over the underlying risk factors should be addressed with the patient's physician.

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:

  • Did individual have symptoms suggestive of a TIA, such as a transient loss of sensation or motor skills, balance problems, vision disturbances, weakness, numbness, or slurred speech?
  • Has individual experienced any significant lapses in memory? Any other signs of altered mental status?
  • Does individual have a history of high blood pressure? Atherosclerosis? Heart disease? Diabetes?
  • Have other blood problems been ruled out?
  • Did the physical exam reveal any characteristic neurological findings, such as visual disturbances or alterations in strength or sensation?
  • Was a carotid bruit noted?
  • Were appropriate clinical lab studies done?
  • Did a Doppler ultrasound of the carotid vessels demonstrate significant narrowing of one or both arteries?
  • If the diagnosis was uncertain, were other diagnostic tests (MRI, CT, MRA or CTA) done to rule out other conditions with similar symptoms?
  • Was stroke excluded as a diagnosis?
  • Was individual referred to an appropriate specialist?

Regarding treatment:

  • Is blood pressure being managed effectively with antihypertensive medications?
  • Were antithrombotics given emergently?
  • Were antiplatelet medications prescribed?
  • Was surgery (carotid endarterectomy) indicated?
  • Were migraine medications considered?

Regarding prognosis:

  • Based on the age, health status, severity of symptoms, and type of treatment required, what is the expected outcome?
  • Does individual have any comorbid conditions that may have affected response to treatment and ability to recovery? Did individual experience any complications of the condition or treatment (such as stroke) that would affect prognosis?
  • Has individual followed recommendations for lifestyle adjustments to reduce atherosclerosis and risk of stroke?

Source: Medical Disability Advisor



References

Cited

Gattellari, M. , et al. "Relative Survival after Transient Ischaemic Attack: Results from the Program of Research Informing Stroke Management (Prism) Study." Stroke: A Journal of Cerebral Circulation 43 (2012): 79-85.

Kleindorfer, D. , et al. "Incidence and Short-Term Prognosis of Transient Ischemic Attack in a Population-Based Study." Stroke: A Journal of Cerebral Circulation 37 (2005): 720-723.

von Sarnowski, B. , et al. "Lifestyle Risk Factors for Ischemic Stroke and Transient Ischemic Attack in Young Adults in the Stroke in Young Fabry Patients Study." Stroke: A Journal of Cerebral Circulation 44 (2013): 119-125.

Zhao, H. , et al. "Abcd Score May Discriminate Minor Stroke from Tia on Patient Admission." Translational Stroke Research (2013): NA-NA.

Source: Medical Disability Advisor