Occupational health worked with allied practitioners to support the return to work of an employee with Guillain-Barré syndrome. Anne Harriss and Su Chantry describe the evidence-based approach that was adopted.
Guillain-Barré syndrome (GBS) is a transient inflammatory neurological disorder characterised by body weakness and numbness.
This case study outlines the OH care of Paul, a 37-year-old, full-time warehouse worker and forklift driver who developed GBS.
Paul’s illness started with a respiratory tract infection that progressed into tingling and numbness in both hands. It eventually involved his arms and legs, and culminated in breathing difficulties. The end result was an emergency admission to the intensive therapy unit (ITU). With intensive medical care, his symptoms gradually improved, the autoimmune inflammatory process diminished and he was transferred to a rehabilitation unit.
Although he made a good recovery, paraesthesia, neuropathic pain and unsteadiness when walking were residual deficits. OH input resulted from a management referral following five months of sickness absence.
Pathophysiology and treatment of GBS
GBS is a potentially life-threatening autoimmune peripheral neuropathy. The immune system attacks myelin around the nerves (Doorn et al, 2008) and is characterised by rapidly progressive symmetrical weakness of the extremities, with loss of muscle function.
In severe cases, respiratory failure and paralysis can occur. It typically becomes progressively worse, plateaus, then resolves with rehabilitative treatment (Tortora and Derrickson, 2015).
Doorn et al highlight that GBS is a rare condition, with one to two people per 100,000 of the population contracting it each year. Eighty per cent of patients fully recover, with 70% experiencing a full neurological recovery within a year. Twenty per cent will be left with some degree of pain, permanent weakness, muscle wasting, and walking difficulties. Onset is rapid and recovery slow, requiring intensive input from physical therapy support to manage residual effects that can last years.
Paul received intravenous immunoglobulin and plasmapheresis, both proven effective treatments (Pikula, 1995). Gabapentin was prescribed for pain management as it has minimal side effects, proving an alternative to opioids and non-steroidal anti-inflammatory drugs (Kumar and Clark, 2012).
Occupational health input
Paul consented to an OH referral aimed at assessing whether or not he could return to his role safely (Palmer et al, 2013).
The nursing process framework (Thornbory, 2014) assisted in achieving the objectives of the consultation, incorporating a four-step approach: assessing, planning, implementing and evaluating a proposed return-to-work (RTW) strategy, including:
- ascertaining the relevant medical issues and current capacity for employment;
- advising on the functional ability of the employee; and
- recommending a RTW plan, incorporating clear timescales and possible adjustments.
The initial consultation with Paul ascertained current and past medical history, family and social history. Details of work history, in conjunction with the pathophysiology of the condition, were discussed, as was the reciprocal impact of health on work.
A bio-psychosocial model of health was used. Social and psychological factors should be considered in developing RTW strategies (Thornbory, 2014; Waddell and Burton, 2004). Murugiah, Thornbory and Harriss (2002) add a further perspective to assessing fitness to work, proposing a framework that considers personal and legal aspects, work characteristics and work environment.
The initial consultation was undertaken over the telephone. Rodway (2014) highlights that phone consultations can enhance OH service access by reducing appointment waiting times, travel time, and by improving continuity and convenience of service. Good telephone skills and the use of standardised templates enhanced the consistency.
Telephone consultations can improve patient choice and empowerment (Rodway, 2014). In this case, it facilitated a swift response to the initial referral. Paul appreciated the opportunity to undertake the consultation from home. Verbal consent was given and documented (Kloss, 2010). All notes were written and recorded electronically on an OH system.
Paul recounted his diagnosis of GBS: one-month ITU admission, followed by a two-month period of neuro-rehabilitation. On discharge home, he received continuing care from a community nurse.
Therapies including counselling, physiotherapy, occupational therapy (OT) and speech and language therapy were available to Paul. Yoga and weekly aqua therapy were scheduled and this improved muscle tone and mobility.
Gobelet et al (2014) emphasise the importance of multidisciplinary team approaches to rehabilitation. Clinical specialists tend not to consider OH to be part of that multidisciplinary team.
Multiple clinicians managing a case provide a diverse range of support mechanisms, helping an individual to achieve a holistic, positive outcome. There is a growing body of UK evidence examining how OT is effective in supporting RTW. The substance of this research straddles the areas of vocational rehabilitation (VR) and OH (Playford et al, 2011).
The OH nurse (OHN) and Paul’s OT collaborated in developing a vocational rehabilitation plan focused on successful RTW, using a needs assessment to underpin goal-orientated rehabilitation plans. It involved coordination of rehabilitation services, clinical treatment, vocational assessments and formulation of RTW programmes focused on his job requirements and within a multidisciplinary framework.
Employment goals are at the heart of VR and aimed at overcoming obstacles to work (Palmer et al. 2013). The basic premise being the individual is employable until proven otherwise.
The Department for Work and Pensions (2004) had good evidence related to restoring function for work. It is acknowledged that much of the research is small scale, with very few longitudinal studies to track ongoing employment rates. The evidence on the types of intervention that best support RTW is contradictory or inconclusive. In order to enhance OH evidence-based practice further, longitudinal research in this field is needed.
Paul found relaying the experiences of his illness during OH consultations distressing. The OHN acknowledged the importance of cognitive and emotional responses of an individual throughout case management, as these often outweigh and outlast physical symptoms (Unruh, 2004).
Paul had difficulties coming to terms with the devastating effects of his condition; a full recovery must incorporate the acceptance of a change of identity as a result of the illness. This is a normal psychological reaction, particularly in chronic conditions (Unruh, 2004). Paul was coming to terms with the changes to his life as a result of his illness. He was managing his current symptoms, but still had some concerns regarding his future.
What one does for a living plays a big part in social conversations; Paul missed work, his colleagues and their companionship. He was eager to informally visit work and meet with colleagues. OHN opinion was that contact with colleagues would boost his wellbeing and sense of work identity following such a protracted absence.
Paul was encouraged to discuss this with his manager, who was advised to maintain regular contact with Paul, sustaining positive links with work, congruent with National Institute for Health and Care Excellence (NICE) (2009) guidance for managers, which recommend sensitive regular managerial contact with employees.
It is a key line-management responsibility to keep in regular contact with absent staff, initiating conversations focused on their wellbeing and their RTW. Managers may feel uncomfortable with such contact. OH and HR professionals can play a key role in supporting and guiding line managers in this process (HSE, 2004).
The OHN felt Paul would benefit from counselling support, as good mental health allows individuals to lead lives that are personally fulfilling, enabling the individual to contribute positively with others (Thornbory, 2014).
Functional assessment and impact of condition on role
There is an expectation that a patient, once recovered, will return to their previous role, with little acknowledgment of the illness, assuming that the individual’s sense of self is unchanged (Gobelet, 2007).
Bernsen (2002) refers to studies examining the RTW experiences of patients with GBS. Participants tended to measure their recovery in terms of returning to work, yet continued to experience certain physical and psychosocial difficulties related to GBS. These required active coping strategies.
In addition, limited public awareness of GBS was perceived as a hindrance when returning to work. Discussion with Paul seemed to confirm this, as some of the anxiety expressed related to a lack of understanding of his condition, with many not knowing what his limitations were. The OHN role in case management can include support and offering guidance to managers to assist in dealing with the employee’s limitations.
Paul reported ongoing weakness in his feet, hands and muscles.
Difficulties in coordination and unsteadiness continued to be significant features of his health, but were improving with physiotherapy.
His upper-body function was improving; however, there was reported intermittent right-arm pain on elevation, and crutches were needed when fatigued.
Paul was able to undertake more and more practical tasks at home, some with the help of his wife. Follow-up studies generally have assessed patients six to 12 months after the onset of GBS, and some studies have reported continued improvements in strength even beyond two years (Walgaard et al, 2011). His OT considered it likely that Paul would require ongoing rehabilitation. This was useful information for his managers.
Current medication was gabapentin, taken to manage neuropathic pain, with reported good effect. It is important that the impact of medications on the employee’s ability to work safely is incorporated within guidance from OH.
Paul’s pain was well managed by the medication, with no reported impact on alertness, so there were no safety-related concerns.
The physical limitations resulting from GBS had implications on Paul’s fitness for forklift truck (FLT) duties. There is detailed advice on medical standards of fitness to drive published by the driver’s medical unit of the Driver and Vehicle
Licensing Authority (DVLA, 2013). Notifiable conditions are anything that could affect the ability to drive safely; neurological conditions such as GBS are included.
Paul’s driving had been restricted as per the medical standards (DVLA, 2013). However, the DVLA has no responsibility for licensing workplace transport drivers if they do not drive on public roads. His competence in an emergency was assessed as unfit related to compromised mobility and paraesthesia in his feet. Paul would need a future medical assessment by OH prior to undertaking FLT tasks.
It was considered unlikely that Paul would regain his full physical capabilities in the near future and in the short term it was unlikely he could return to the very physical nature of his job.
Immobility was the main barrier to returning to work. Currently, it was considered unsafe for Paul to undertake his job. A vocational rehabilitation plan was devised with collaboration of OT and OH and Paul was advised to start some voluntary work as part of his long-term focus on returning to his role. This was well received.
Harrington, cited in Thornbory (2014), states that the OHN needs to consider the applicability of the disability element of The Equality Act 2010. For a condition to fall within the remit of the Act, it must be substantial, long-term and impact on daily living activities, with each condition being assessed in the hypothetical sense as if the individual were not receiving or had not received treatment.
The ultimate decision is made by the chairman of the Employment Tribunal – ie, the legal profession rather than the medical profession.
Notwithstanding this, and due to the long-term nature of GBS, it is likely that this case would be considered under the disability provisions of the Equality Act. The manager will need to be aware of this under the duty to make reasonable adjustments. It is, of course, a management decision regarding adjustments that can be accommodated.
OH can advise management further if needed. It is helpful to inform management that an Access to Work grant – a Government initiative that provides advice and practical support to the disabled who are employed – can provide practical support for employees returning to work with a disability (HM Government, 2011).
Returning to work is a crucial step to returning to good health (Waddell, Burton and Kendell, 2008) and the consideration of adjusted duties under the provision of the Equality Act would need to be addressed at an OH review.
OH and OT were keen to explore alternative roles that Paul could return to, both sharing expertise from a VR perspective.
Once recovered, a functional capacity evaluation (FCE) of Paul would determine functional capabilities. An awareness of what the employee can physically do, their potential for work, and the safe work restrictions and endurance, is integral to developing a RTW (Matheson, 2003).
The report was written and sent electronically, adhering to the informed consent process and internal policy for report release. The content included answers to specific questions posed by the manager. The impact of the condition on functional capacity and a statement of fitness was declared. OH advice was evidence based and aimed at enabling Paul to be managed successfully.
Although Paul had not yet been able to successfully RTW, the positive outcome of the consultation was that assessment of fitness and advice was provided for management to support Paul further.
Links were made between OH with OT and a plan was established for ongoing management of the case. It is hoped that ongoing dialogue with the multidisciplinary teams will result in a successful, rehabilitated RTW in the future.
Advice was given to the manager on how to support Paul with the disability, recommending workplace adjustments that would need to be considered; this is a positive outcome of the occupational health consultation.
Neurological deficit was a dominant, residing physical feature, and it was clear that the impact of the condition had resulted in psychological concerns along with social factors. The bio-psychosocial model of health covered all of those aspects in this case.
The goal for Paul and the team managing his rehabilitation was more than clinical recovery; the focus was a successful RTW. Paul had not achieved the goal during the initial contact with OH. However, collaboration with OT supported the employment goal and continued to be at the heart of the VR plan.
Su Chantry RGN, Dip HE, Queen’s Nurse, is senior occupational health nurse and vocational rehabilitation case manager. Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, PFHEA, NTFHEA, Queen’s Nurse, is associate professor occupational health nursing, London South Bank University.
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