A prolapsed lumbar disc can cause intense pain, numbness and tingling through the hips, buttocks, legs and feet, affecting mobility and ability to work. As Farah Akram and Professor Anne Harriss explain, occupational health can play a pivotal role in managing an employee’s absence and leading on their return to work.
This case study-based article considers the impact of a prolapsed intervertebral disc (PID) on Harriet (pseudonym), a 35-year-old staff nurse practicing on a rehabilitation ward.
About the authors
Farah Akram is a specialist occupational health nurse and Professor Anne Harriss is emeritus professor in occupational health
Harriet’s manager referred her to the occupational health (OH) service prior to her return to work (RTW) following a five-week period of sickness absence resulting from a PID. The Royal College of Physicians’ national clinical audit of back pain management has found 40% of NHS sickness absence relates to back pain and musculoskeletal disorders (Nursing Times, 2012). Its report identifies the importance of early intervention from OH in supporting staff to RTW.
A PID results from the rupture of the disc nucleus following an injury to the outer fibres. It may occur suddenly or gradually over a sustained period of time (Medanta, 2017). The NHS (2018) notes that such prolapses may result from range of factors that relate to nurses. These include ageing, inactivity, obesity and poor lifting techniques.
Although disc prolapse may be associated with age-related degeneration, Bohinski (2018) also notes other factors, including, genetics, smoking, occupational and recreational activities, increase the risk of developing prolapsed disc.
Symptoms depend on the disc that has prolapsed and include pain and numbness or tingling that may radiate into the hips, buttocks, down the legs and into the feet, particularly so if the disc presses on the sciatic nerve (NHS, 2018).
Occupational health assessment
The purpose of the assessment was to ensure Harriet was able to perform her work task effectively without risking the health and safety of herself, colleagues or patients. It provided an opportunity to recommend job modifications/role adjustments, thus permitting them to not be excluded from work and to be able to work safely (Palmer et al, 2013).
Integral to her role as a nurse are risk factors such as manual handling tasks and standing for long periods of time. Assessing functional ability and documenting a clinical history aids the OH practitioner (OHP) to identify any impairments relevant to the individual’s work facilitates recommending appropriate modifications (Smith and Harriss 2016).
Following triage of the referral, Harriet was allocated a face-to-face appointment. Although telephone OH consultations are becoming more common practice – and were especially important during the coronavirus lockdown – the OHP is deprived of non-verbal cues (Medical Protection, 2015). Furthermore, face-to-face assessments provide opportunities to observe the extent of any difficulties in mobility and utilising visible cues regarding the extent of pain, both useful indicators for clients with musculoskeletal conditions (Smith and Harriss, 2013). A biopsychosocial model provided a structure to the assessment providing an interactive and individual-centred approach that considers the person, their health problem, within their social/occupational context (Aylward et al, 2013).
Presenting illness
At the time of the assessment, Harriet had been absent from work for five weeks following an exacerbation of her chronic back pain. Her GP-issued fit note confirmed her fitness to return to work with “modified duties and hours”. OH was therefore asked to recommend a return-to-work strategy.
The history taken by the OH practitioner revealed that Harriet had developed increased frequency of lower back pain, with pain radiating down both legs and with tingling and numbness in her toes. She had difficulty bending, which had worsened over a period of one week. Her symptoms increased in severity until eventually she was unable to attend work. Harriet was reviewed by her GP, who requested an MRI. This indicated a large disc prolapse at L5. Her GP advised her to rest at home to facilitate her recovery and avoid a hospital admission
Pathophysiology
To further understand Harriet’s condition and its functional limitations, the normal anatomy and function of the spine and pathological basis of her symptoms is explored. The spine consists of 24 vertebrae stacked on top of one another creating a canal protecting the spinal cord; five vertebrae (L1 to L5) make up the lumbar spine (Orthoinfo, 2019).
Symptoms associated with a disc prolapse depend on location of the herniation. With respect to a herniated lumbar disc, symptoms may include pain radiating from the lumbar area, down one or both legs, and sometimes into the feet. There is severe pain when standing, walking or sitting. Activities including bending, lifting, twisting, and sitting may increase the pain. (Bohinski, 2018). In Harriet’s case, she may have sustained an asymptomatic annular tear prior to the development of her pain, consistent with the findings of her MRI scan.
Social history
Harriet disclosed the recent death of her father. She was unable to attend the funeral due to travel issues, a cause of significant stress.
Although previously inactive, undertaking less than one hour of exercise per week, she had recently started training for a 10K run, aiming to increase her fitness levels and raise money for charity.
She questioned whether increasing her exercise activity significantly, combined with the stress associated with the loss of her father, may have contributed to her current back pain flare-up.
Treatment
To establish fitness for work, Harriet’s treatment regimen and the functional impact of any side-effects were considered (Palmer et al, 2013). According to Ortho info (2019) non-surgical treatment for prolapsed disc can include the following:
- Resting – taking regular breaks throughout the day, slowing down and controlling physical activity as well as avoiding activities that aggravate the pain.
- Non-steroidal anti-inflammatory medications.
- Physiotherapy – focusing on strengthening lower back and abdominal muscles.
- Epidural steroid injections.
Harriet’s GP considered that, with rest and non-surgical interventions, her PID might resolve over the next few weeks. Naproxen was prescribed for pain management and she was referred to the physiotherapy service.
Employment history
Determining Harriet’s fitness to RTW required consideration of the functional demands of her job. Harriet’s work as a rehabilitation nurse was both intellectually and physically demanding.
Physical demands included ergonomic factors such as manual handling and prolonged periods standing, resulting from her being responsible for providing care to patients with physical disability and chronic illness.
Her job demands including supporting patients in adapting to an altered lifestyle, whilst providing a therapeutic environment for clients and their families. This intensity of work therefore demanded considerable intellectual skill and resilience.
It was important to understand Harriet’s work processes, job roles and the culture of her workplace (Harrington, 2019). She was required to undertake shift work, including night duties. Her rota normally incorporated four 12-hour shifts each week, generally including four-night shifts per month with a maximum of three shifts consecutively, in line with ward policy.
Identifying exacerbating and relieving factors are essential to effectively manage lower back pain disorders (Harriss and Mnkandla 2018). During periods of remission, Harriet reported night shifts had little impact on her condition, as she slept well during the day.
In the weeks leading to her recent episode, however, back pain had disrupted her sleep, with her routine further unsettled by frequent rotating shifts. This change had led to something of a vicious cycle, as the further exacerbation of her symptoms had, in turn significantly disrupted her sleep.
Harriet also reported that taking rest breaks was dependent on workload, with breaks usually only lasting 10 minutes to eat a meal. The importance of taking breaks, especially during her recovery was emphasised. Harriet was asked as if she perceived any barriers to her RTW. She denied any work-related stress and described having a supportive line manager.
Legal aspects
Under common law, Harriet’s employer has an obligation to take reasonable care of employees and to guard against risk of injury. However, employers have a higher duty of care to any particularly vulnerable employee with a known, pre-existing medical condition (Palmer et al, 2013).
Section 2 of the Health and Safety at Work etc. Act (1974) requires Harriet’s employer to ensure, so far as is reasonably practicable, her health, safety and welfare at work. Furthermore, Regulation 3 of the Management of Health and Safety at Work Regulations 1999 requires her employer to assess risks to her health and safety.
The Equality Act (2010) sets out that discrimination due to disability is unlawful. Under this Act, if an individual has a physical or mental impairment having a substantial long-term adverse effect on the individual’s ability to perform day-to-day activities, it could constitute a disability (Pritam, 2011). Therefore, the OHP must remain cognisant of the importance of assessing function, rather than just considering the condition itself.
Harriet’s manager did not raise the question of whether the Equality Act (2010) was applicable, therefore this was not referred to in the OH report. The role of the OHP is to make recommendations of possible adjustments the employer might consider implementing (OH Law Online, 2019) but the decision as to whether these are reasonable rests with the manager.
Rehabilitation and role of the occupational health nurse
Vocational rehabilitation aims to restore injured workers to productive working roles. Harriet expressed her motivation to RTW, noting that work would benefit her psychological wellbeing. This reflects extensive evidence that work is generally good for health (Waddell and Burton, 2006; Marmot, 2008).
Furthermore, encouraging and supporting Harriet to RTW as early as possible has many benefits. For instance, the Fit for Work (2016) blog highlights that “being in work is good for health, wellbeing and brings financial security; returning to work brings routine and a sense of normality after illness. It increases self-respect, and boosts mental health and social inclusion; good RTW process aims to increase speed of recovery and prevent potential relapses or complications resulting from continuing to be off work.”
The work of Whitaker and Baranski (2001) published by the World Health Organization suggests that the OHPs may fulfil several inter-related roles in workplace health management, including: clinician, specialist, adviser, health educator and counsellor.
Reflecting on Harriet’s case, it is evident the OHP assumed all of these roles. The assessment of her fitness for work required “clinician” and “specialist” skills. Listening and problem-solving skills were essential for health promotion including discussing sleep hygiene and resilience strategies, requiring expertise as a “health educator” and ‘counsellor’. The OHP role as an advisor included providing advice to Harriet’s manager to ensure successful RTW.
Recommended adjustments
As Harriet was deemed fit to RTW by her GP, the role of the OHP was then to undertake a fitness for work evaluation in a way whereby the individual’s capabilities are compared to job functions/demands and provide manager with report on individuals capabilities, limitations and applicable restrictions (Guzik, 2013).
Issues pertinent to Harriet’s rehabilitation included:
- Recovering from fatigue and reduced stamina.
- Treatment/medication (including side-effects).
- Managing stress.
In view of the above, several adjustments were recommended to Harriet’s manager and are outlined below as follows.
- A phased return of working hours. A phased RTW aids the process of bridging sickness absence and normal working; by gradually building up to the usual hours and/or job duties over an agreed time period (Fit for Work, 2016). A phased RTW supported Harriet to increase her stamina and better manage residual fatigue.
- Gradually introduce night shifts after phased return. Harriet identified the impact of night shifts during the relapse. Maintaining a regular daytime shift pattern during the early period of her absence would support her return and recovery.
- Phased return of duties. Harriet considered herself able to undertake the physical demands of her work tasks but management were advised that a combination of different work activities plus alternating sedentary work with physical tasks might avoid fatigue. Gradually increasing the complexity of nursing duties aimed to develop Harriet’s confidence, physical and intellectual stamina.
- Regular/flexible rest breaks. Regular rest breaks were recommended with the aim of supporting Harriet in managing fatigue.
- Time off for medical appointments. Harriet required regular appointments with her treating physiotherapist as recommended by her GP.
- Manual handling risk assessment. Workers returning to work following back pain benefit from risk assessment of manual handling tasks to prevent further exacerbating their condition (Health and Safety Executive Northern Ireland (HSENI), 2019).
- Work-related stress risk assessment. Harriet’s employer has a legal duty to protect her from stress at work (HSE, 2017). Undertaking a risk assessment and taking appropriate action was integral to this process to be was undertaken in the light of her recent prolapsed disc. Workplace mental stress increases the risk of developing chronic back pain (HSENI, 2019). Therefore, identifying methods to limit reduction of stress at work where possible should be considered.
Conclusions
This case study has examined the reciprocal effects of illness on Harriet and on her ability to undertake her normal work processes, taking an integrated approach to determine Harriet’s fitness for work, based on a biopsychosocial framework.
Pathophysiology was explored to consider how Harriet’s symptoms may continue to influence her work capability. The functional demands of her job were addressed, along with potential barriers to a successful RTW. Finally, workplace adjustments were proposed to assist with an effective RTW strategy and her return to work was uneventful.
It is evident that early intervention from OH is beneficial in managing long-term sickness absence effectively. Therefore, future practice could be improved by ensuring a more timely OH referral. Similarly, there would be value in highlighting that OHPs consider opportunities to educate managers regarding approaches to managing attendance, stressing the benefits of early OH input, and the beneficial effect this input has on RTW for both the employee and employer.
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