Returning to work after surgery

One of the more challenging questions asked of occupational health (OH) practitioners is: “When can X return to work after their operation, and what temporary adjustments would you recommend?” We assume this should be an easy question, but how do we find the answer? I will look at the main issues to consider when advising management and employees.

What are the employee’s concerns?

It is important to consider why management want to know, and how this may affect the employee. As always, there are broadly two groups of employee: those who are keen to return to work as soon as possible (often for financial reasons), and those who want to stay off as long as possible (often because there is no financial incentive to return). In among these are those who are not worried about returning, and those who are worried that a return too early might be harmful. It is important to work out early on which group the employee belongs to.

Who to ask or where to look for answers

The most obvious source of information would be the surgeon or the GP. Most OH advisers (OHAs) will have some doubts about this because of differing advice given.

A study¹ asked 100 surgeons and 100 GPs what advice they would give to patients returning to various job types. The results were striking; for example, advice from GPs for 55-year-olds returning to heavy manual work following inguinal hernia repair varied from two to 16 weeks, and advice from surgeons varied from two to 12 weeks. The logical conclusion is that in most cases, the advice is not based on evidence, and is not particularly helpful. Many specialists don’t actually know when patients can return to work because there is no evidence.

The variation will inevitably lead to issues with employees who want to remain off as long as possible. They are likely to have sought advice from several sources and hope for the longest possible time off work. They may well open the consultation with the statement: ‘I suppose you are going to force me back to work then…’

These consultations are often a challenge, potentially placing the OHA between manager and employee in conflict with both, in an absence of evidence, with illness behaviour and incorrect advice from treating clinicians.

The first point is not to take sides; you are there to advise, not dictate. If management are happy to let the employee stay off for long periods, that is a matter for management. Your primary concerns are to give management as much evidence-based advice as you can, and to give the employee good advice about rehabilitation to ensure they are not harmed by returning too early, or harmed by prolonged inactivity.

It will help if you identify all the hidden agendas from the start, so open up with a few questions such as ‘what have you been advised already?’, or ‘what are your main concerns?’, and see how they respond to the suggestion of an earlier return with adjustments.

Is there any evidence for recovery time?

There is very little evidence, and some of it is surprising. After carpal tunnel surgery,² surgeons’ advice for time off work varied from one day to 36 days, and the actual return-to-work date varied from one day to 88 days. There was no advantage to delaying return, and the main predictor for time off was the advice given by the surgeon.

After lumbar discectomy,³ patients were encouraged to return to full activities as soon as possible. The mean time to return to work was 1.7 weeks, and 25% returned the day after surgery without any long-term ill effects. After inguinal hernia repair,⁴ manual workers averaged a return to work after 10 days with no adverse outcome, compared to delayed return.

Those of us familiar with animals will know that after surgical procedures most are up and about within a day or so, and are running around the garden if allowed within three or four days. So for many procedures, it is likely that people will not be harmed by returning to work very quickly. They may well, however, experience discomfort, and this is an important consideration.

In the absence of evidence, what can we do?

A logical approach is to look at wound healing, and extrapolate from this. Without sutures, soft tissues will heal over a period of several weeks. The initial processes of laying down collagen fibres, development of new blood vessels and epidermal migration lead to the weakening of local structures over the first couple of weeks.

Strength is back to 70% of intact tissue after around six weeks, and 80% by 12 weeks. The resulting scar will never be as strong, and is likely to remain at around 80% strength after this.

Modern surgery does not, however, leave the wound open to heal. Sutures hold the wound together, and where there is concern over structural strength, mesh or tape can be used to support surrounding tissues. As a result, the strength of an inguinal hernia repair is around 70% of intact tissue immediately after surgery.⁵

A simple understanding of the operative procedure will allow you to assess the likely risk, and if you have the opportunity to discuss this with the surgeon you may get a more useful response than just asking how long the patient should remain off.

At a recent discussion at the Royal College of Obstetricians and Gynaecologists, it was acknowledged there was very little evidence for risk after hysterectomy. However, concern remained about the weakening of structures internally following hysterectomy by any route. We might assume that a vaginal hysterectomy causes minimal disruption, but some tissues will be cut. While the words ‘could’ and ‘might’ were commonly used in the discussion, it was agreed that before trying heavy lifting, a recovery period of four to six weeks would be prudent. Much of the guidance available is consensus developed in this way.

Hysterectomy is not the only procedure that can be done in a variety of different ways, with significantly different risks during recovery. Bunion surgery is something that we might assume is one simple procedure, but can involve just a shaving of bone, or significant repositioning of ligaments and tendons, or a metacarpal fracture and realignment with or without internal fixation. The risk of early weight-bearing varies considerably between these four procedures, so it is important to find out exactly what was done, and ask the surgeon for his recommendations too.

Using consensus among specialists represents the best approach in the absence of evidence. It is apparent when seeking consensus that views vary significantly between nations and there are social reasons for this. The surgical training process may pass on entrenched views, and societal behaviour plays a part. The UK has a history of generous sick pay schemes and prolonged absences after surgery, unlike other European nations and others. As a result, our consensus view may well be conservative.

Attempts have been made to seek consensus for many procedures. An OH study of surgeons in the south-west of England in 2007 produced useful tables, and there are other sources such as the Faculty publication Fitness for Work.⁶ These sources have been combined by the author along with other evidence to produce a more comprehensive table accessible on the internet.⁷

The Royal College of Surgeons⁸ and the Royal College of Obstetricians and Gynaecologists⁹ recently developed consensus guidelines. The results of these represent a useful resource for patients preparing for and recovering from surgery, as well as OH advisers.

What factors should we take into account when giving advice?

There are two main issues. The first is to determine whether the employee will be harmed by returning to work. This assumes a very motivated patient who will put up with significant pain and discomfort to return early. ‘Harm’ generally means wound failure, herniation or other structural failure. In most cases, significant harm is very unlikely, but where the wound is large or where there is a bone fracture, early activity could lead to substantial complications with long-term consequences.

In most cases, the problems are pain or discomfort, and lack of physical fitness or capability. Deciding how much pain an employee would be expected to sustain is not the role of the OH adviser. It would be reasonable to comment on this – for example, to say after an inguinal hernia repair ‘X will not be harmed by returning to work within a few days, but is likely to experience pain and discomfort for a few weeks’.

There are other underlying health factors that can have a major impact. Diabetes interferes with the process of revascularisation and impairs communication with neutrophils and macrophages. Obesity results in reduced circulation within the subcutaneous layers. Both slow healing and increase the risk of wound infection.

Smoking impairs tissue oxygenation directly by reducing available oxygen, and indirectly through vasoconstriction caused by high nicotine levels (although low dose nicotine has been shown to promote new vessel growth, reinforcing the advice to swap cigarettes for nicotine patches).

Can employees be harmed by remaining off work too long?

Employees who remain off work for more than three months will generally begin to feel less confident about working effectively immediately on their return, and evidence shows a dramatic drop in numbers of employees returning at all once they have remained off for around six months. So the greatest harm could be losing their job.

There are, however, more important general issues about prolonged recovery. Many middle-aged employees who take prolonged rest after surgery never recover full fitness. Inactivity for three months leads to substantial loss of physical fitness, and although a return to some work may be possible, in some cases the employee is simply unable to regain sufficient fitness to work effectively full-time again. This is not just an issue of work, but it is an issue of lifestyle and long-term health.

In general, some physical activity is to be encouraged immediately after surgery, building up to normal as soon as possible, ideally within the first week or two. It may take significantly longer to return to heavy manual work, but not to return to general every-day activity. The advice given is usually to rest initially, then build up light activity. This is sensible advice, but it has not changed much for 50 years, while lifestyles have changed substantially.

After many procedures, the guidance emphasises the value and importance of walking as soon as possible, to get moving, help circulation and reduce the risk of deep vein thrombosis, to prevent loss of fitness, and to get the mental health advantages of exercise and social contact. It seems entirely reasonable to advise just light walking of around 10 minutes a couple of times a day in the first few days, building up towards 30 minutes walking two or three times a day by the end of the first week. This is presented as ‘light activity’ because for humans, it is. For 21st century humans, it is not.

When we advise ‘light activity’ of a couple of 10-minute walks each day, we are talking about 1,000-3,000 paces a day. So where we are advising people to take ‘light exercise only’, we may actually be advising them to do substantially more than they normally would from the moment they wake from the anaesthetic, and often more exercise than they would do on a working day after a week or so.

This is where the OH adviser can make a real difference, explaining the risks and benefits clearly to the employee who may inadvertently have changed from a sedentary lifestyle to a sessile lifestyle. If they have been very inactive prior to surgery, this is their opportunity to get fitter than ever. If they want to stay off work for a while and recuperate, they should use this opportunity to improve their fitness before returning.

This is a much more positive message; advise them to be active for their own health. If they wish to return to work they can, but if they are allowed to stay off they should exercise, not lie back and watch TV.

Dr Tony Williams MA MB BChir MMedSci LLM DTM&H FFOM is director of Working Fit, an occupational health consultancy.

References

1 Majeed AW et al. Variations in medical attitudes to postoperative recovery period. BMJ 1995;311:296.

2 Ratzon N et al. Time to return to work and surgeons’ recommendations after carpal tunnel release. Occupational Medicine 2006;56(1):46-50.

3 Carragee EJ et al. Are postoperative activity restrictions necessary after posterior lumbar discectomy? A prospective study of outcomes in 50 consecutive cases. Spine 1996; 21(16):1893-7.

4, 5 Schulman AG et al. Returning to work after herniorrhaphy. BMJ 1994;309:216-7

6 Palmer KT, Cox RAF and Brown I. Fitness for Work 4th edn. Oxford University Press, Oxford 2007.

7 www.workingfit.com

8 www.rcseng.ac.uk

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