Msd_Assignment

Content Chapter 1: introduction 1.1 Background 1.2 Aim and Objective 1.3 Resume of the client 1.4 Order of care study | Page 2-44-555 | | Chapter 2 2.1 Client profile2.2 Pathophysiology 2.3 Pathology of acute inflammation 2.4 Mechanism of acute pain | 5-77-88-1111-13 | | Chapter 3 3.1 Assessment of fitness to work | 13-17 | | Chapter 44.1 Conclusion and recommendations | 18-19 | | References | 20-23 | | Appendices Appendix 1: job descriptionsAppendix 2: OH referral Appendix 3: fitness to work frameworkAppendix 4: Prescribed analgesia (Gloria)Appendix 5: physiotherapy letter | 2425262728 | | Chapter 1 1.0 Introduction 1.1 Background Musculoskeletal Disorders (MSD) are one of the main reasons patients’ attend local General Practitioners (GP) and Accident and Emergency (A&E) departments. MSD’s can have significant effect on a workplace, productivity and employment. However, early intervention, right diagnosis and treatment can expedite an early return to work and reduce adverse effects or escalation to other problems (Bevan 2007). According to the Health and Safety Executive (HSE) (2009) “About 20% of all work-related musculoskeletal disorders affect the lower limbs.  In 2009/10 an estimated 94,000 people in Britain who had worked in the last 12 months suffered from Lower Limbs Disorder caused or made worse by their work”. Cox et al (2007), state that “Most morbidity in the working population arises from acute soft tissue or bony injury” and in 2005 -2006 over 1 million work-related sicknesses were caused by Musculoskeletal Disorders (MSD). The Equality Act (2010) places responsibility on employees and employers to evaluate the impact of physical health on safety and performance at work and make reasonable adjustment were appropriate (Oakley 2008). MSD may develop or attributed to be working while maintaining an awkward posture or being unbalanced, performing manual handling and sustaining soft tissue injury like ankle injury (HSE 2004). Norris (1998) defines the ankle as the articulation between the trochlear surface of the talus and the distal ends of the tibia and fibula. The fibula supports up to 20% of human weight. “The ankle is a complex joint that is capable of a wide range of movement: flexion, extension, inversion and eversion as well as a combination of other movements. All this is necessary for locomotion and to traverse uneven ground” (Wright et al 2012). Noakes & Granger (1996) indicates that, there are types of ankle injuries, which includes Stress fractures, inversion and eversion strain. Inversion strain is when the heel bone is moved inwards or the big toe is pointed downwards and inwards. Eversion strain, pain is felt below the inner ankle bone along with swelling and bruising will discolour the foot. Stress fractures of the calcaneus, pain is localised to the bones of the foot. Stress fracture of the cuboid bone is unlike other stress fractures it does not cause severe pain (Noakes & Granger 1996). Further assessment shows that ankle injury can cause instability; the severity is based on the level injury caused. However, in this case risk assessment was required to ascertain if it is suitable for her working environment (Wilson 2002). Cox et al (2007) state that “any occupation demanding stability of the ankles may be affected by such injury”. Lifting, working on heights, carrying and climbing will become difficult tasks and unsafe for an employees with an unstable ankle. Figure1: Ankle and ligaments that maintain articulation http://www.arthroscopy.com/sp09005.htm (Accessed 13 May 2012) 1.2 Aim and Objectives The purpose of the study is to elaborate on the impact of soft tissue ankle injury and the ability of the employee to carry out her work. The assessment of fitness to work was aimed to rehabilitate employees back to work safely. Objectives include the followings: * Discussion of the soft tissue ankle injury that has adversely impacted on the employee’s ability to carry out his/her task. Mainly the pain caused by the strain of the ankle. * To critically evaluate the assessments used by the Occupational Health Practitioner (OHP) to determine clients fitness for work. * To reflect on the OHP’s role in their provision of care, with the view of improving future practice where appropriate and by making recommendations if necessary. 1.3 Resume of client The employee in question was Gloria (fictitious name used in accordance with the Nursing and midwifery council) (2008) was referred by management to Occupational Health Department to undergo a fitness to work assessment as a train driver with pain to her left ankle preventing her from performing her present duties. 1.4 Order of the case study Chapter 2- Will look at the pathology of the soft tissue ankle injury, inflammation and pain. Examine how the injury impacts on Gloria’s ability to function and also a client profile will be established. Chapter 3- Will analyse and evaluate the Occupational Health Nurse’s role in assessing Gloria’s fitness to work. Chapter 4- Will reflect on the role of the Occupational Health Nurse in the care provision for Gloria and future practice. Chapter 2 2.1 Client Profile Gloria was a 44 year old woman and has been working as a train driver (See appendix 1 for job description) at a transport company for 8 years. She’s a dedicated worker with minimal time off for sickness and has no history of musculoskeletal disorder. She has high level of fitness and enjoys trekking, jogging and walking. However, there is a pre-disposing factor, which includes manual task such as heavy lifting and walking on uneven surface (See appendix 1 for job description) as a result of her ankle injury she is unable to undertake these task as they are safety critical tasks. Gloria suffered an inversion injury to her left ankle; she fell off the stairs at work, while walking in the depot to her train. Though first aid was administered, she visited the A&E next day when the pain became unbearable; it was discovered that she had some ligament (soft tissue) to her left ankle. Dandy & Edwards (2009) describes a sprained ankle as the commonest ankle injury of all and it is a partial tear of the anterior inferior talofibular ligament caused by a sudden adduction of the foot when an ankle is plantar-flexed. Most of the time, the person feels the pain at the time of the injury and on examination by medical personnel (Dandy & Edwards 2009). Figure 2: A typical sprained ankle. http://sprainedanklerehab.org/what-is-a-sprained-ankle/ (Accessed 15 March 2012) The next section will provide an overview of a sprained ankle and factors that might hinder Gloria’s immediate return to work. Gloria being a train driver was a safety critical role and as such a physical task was involved (see appendix 1 for job description), as part of Gloria’s safety critical role/ task is to walk on live track during emergency evacuation, such walking customers on track to safety or nearest station. Therefore, she needs to be physically capable as she will be walking on an uneven surface. Gloria she was unable to embark on these tasks at present due to sprained ankle resulting to swelling and pain. More so, according to the company’s stringent policy and procedure, Gloria would have been restricted from her present duties as she was on medications such as co-dydramol, which can affect her decision making when carrying out her task (see appendix 4 for prescription). Due to limited word count of the case study, Gloria’s prescribed medication will not be discussed within the text but can be located in appendix 4. 2.2 Pathophysiology Ankle Injury (Sprained ankle) According to Sambrook et al (2010) the ankle is very commonly injured during a range of normal daily activities, including walking; people with history of a previous ankle sprain has five times increased risk of suffering a further ankle sprain. Mostly pain from a sprained ankle subsides after 8-10 days, but it might still be uncomfortable for up to 12 weeks. It may be even be worse if the ankle is accidentally twisted again and the pain can last up to 2 years (Sambrook et al 2010). The ankle or talocrural joint is a hinge that is formed by articular facets on the distal tibia, the medial malleolus and the lateral malleolus, which articulate with the talus (Voight et al 2007). Gloria’s ankle displayed obvious swelling and tenderness, a classic symptom of a sprained ankle. The tibiotalar joint is a hinge joint, while movement is limited to plantar (downwards) and dorsiflexion (upwards). The fibula articulates on the lateral side of the tibia but it does not bear any weight at all. A Subtalar joint allows the foot to be inverted or everted (Sambrook et al 2010). Figure 3: swollen, sprained and damaged ligament of the ankle http://www.howtotreatasprainedankle.org/category/how-to-treat-a-sprained-ankle (Accessed 13 March 2012) The Most stable position of the ankle is dorsiflexion as the talus is wider on the anterior than posteriorly; as a result the talus fits tighter between the malleoli. When the ankle moves into plantarflexion the wider portion of the tibia comes into contact with the narrower posterior aspect of the talus, creating a less stable position (Voight et al 2007). 2.3 Pathology of acute inflammation When Gloria slipped and fell she twisted her ankle. The injured cells in the ankle released inflammatory mediators via the cyclo-oxygenase pathway, which explains pain, swelling and inflammation she felt which the contributed to immobility. The cyclo-oxygenase pathway will be explained further. The function of Inflammation in acute injuries is to improve the flow of blood cells and chemical mediators to the affected area. When these cells and mediators at the site of injury, they destroy, dilute and barricade all injurious agents to allow repair and healing to commence (Kumar & Clark 2009). Acute inflammation is mediated by granulocyte normally but leukocytes also release inflammatory mediators which develop and maintain the inflammatory response. Leukocytes are receptors- mediators, and are essentially involved in the maintenance of inflammation. These cells must be able to get to the site of injury from their usual location in the blood, therefore mechanisms exist to recruit and direct leukocytes to the appropriate place. The process of leukocyte movement from the blood to the tissues through the blood vessels is known as extravasation (Woolf 2000; Porth 2007). Chemokine stimulates the leukocytes to move between endothelial cells and pass the through membrane into the tissues. Chemo attractants cause the leukocytes to move along a chemo tactic such as histamine, towards the source of inflammation (Woolf 2000). Histamine is a chemo tactic for eosinophils. It is one of the first mediators that are released in response of trauma. It’s stored in granules in mast cells to dilate and increase permeability of venules in the immediate transient phase. More so, serotonin has the same effects as histamine, and they are both located and released from platelets upon activation. Mast cells are also stimulated by activated complement proteins, especially C3a and C5a, which are also inflammation assets. Platelets are initially activated by contact with collagen, consequent adhesion and platelet activating factor (PAF) such as nitric oxide and cytokines (Adams 2006; Playfair & Chain 2005). Furthermore, Playfair & Chain (2005) state that some chemical mediators can cause damage healthy tissue or causes excessive scar formation by cells called fibroblasts, particularly when inflammation persists. Cyclooxygenase (COX) is an enzyme , which provides relief from the symptoms of inflammation and pain. Non-steroidal anti-inflammatory drugs (NSAID), such as diclofenac and ibuprofen, exert their effects through inhibition of COX, as in Gloria’s case. Arachidonic acid is converted by COX pathway to synthesize different prostaglandins, which stimulate many other functions within the body. There are two different types of COX. COX-1 is built in many different cells to create prostaglandins used for basic housekeeping messages throughout the body and COX-2 is built only in special cells and is used for signalling pain and inflammation. Both produce different types of prostaglandins (PGE1 and PGE2) (Porth 2007; Woolf 2000; Playfair & Chain 2005). Figure 4: The Cyclooxygenase pathway http://www.chm.bris.ac.uk/motm/ibuprofen/drug_action.htm (Accessed 12 May 2012) Swelling occurs when vessels are engorge with blood, the hydrostatic pressure rises and this leads to leakage of plasma and plasma proteins out of blood vessels and into surrounding tissues within the ankle.  This results in localized swelling, and would account for Gloria’s swelling. To reduce Gloria’s swelling around her ankle she needed to elevation the ankle (Goodnow, 2007; Porth, 2007). 2.4 Mechanism of acute pain Figure 5: Pain Transmission http://www.cybermedicine2000.com/pharmacology2000/Central/Opioid/pathway10.htm (Accessed 21 March 2012) Pain is mediated by free nerve ending nociceptors. Chemicals mediators are released after injury occurs, which may result in pain Gloria encounter (Kumar & Clark 2009). A-delta fibre indicates the perception of sharp and immediate pain and then diffuse prolonged pain is mediated by slower-conducting C fibres (Bogduk 2002; Kumar & Clark 2009). The prostaglandins’ produced by the injured cells in Gloria’s ankle will sensitize A delta fibres. A-delta pain is fast and sharp pain, resulting from mechanical or thermal stimuli (Porth 2007). While C fibre pain is more of a slow-wave pain and is caused by chemical stimuli, it can also occur as a result of persistent mechanical stimuli (Bond & Simpson 2006). Nociceptive Pain arises from the stimulation of specific pain receptors, histamine, potassium and bradykinin. These receptors can respond to heat, cold, stretch and chemical stimuli released from damaged cells (Playfair and Chain 2005). In Gloria’s case the receptors responded to heat (inflammation), which was felt around her ankle during consultation (Porth 2007). There are two types of nocieptive pain Visceral and somatic pain. Somatic pains are often sharp and well localised, and can often be reproduced by touching or moving the area or tissue involved, as in Gloria’s case. As soon as nociceptors are stimulated they spread signals through sensory neurons in the dorsal horn, and in spinal cord. These neurons release the neurotransmitter glutamate at their synapses. The nociceptive neurons release neurotransmitters, noradrenalin, 5-HT, gamma amino butyric acid noradrenaline and glutamate which transmit impulses (Bond & Simpson 2006). From the spinal cord, projection neurons ascends into the neospinothalamic and paleospinothalamic tracts of anterolateralpathway, with the neospinothalamic containing A-delta fibres transmitting very fast sharp pain to the thalamus, while C fibres through the paleospinothalamic tract goes in the reticular formation of medulla, pons and the midbrain. (Bogduk 2002; Kumar & Clark 2009; Porth 2007). Gloria’s assessment regarding fitness to work will now be evaluated. Chapter 3 3.0 Assessment of fitness to work Gloria was referred by management to OHN (see appendix 2 for referral form) in order to minimise her sickness absence and explore a prompt rehabilitation programme. Reducing the amount of swelling and controlling her pain effectively can significantly reduce the time required for rehabilitation (Voight et al 2007). The referral was appropriately written, which included the actual reason for the referral and Gloria’s consent, as advocated by Lewis & Thornbury (2010). More so, Cox et al (2007) also specified that even though an actual diagnosis not need to be given in the referral, the employees written consent is needed. An assessment of fitness to work was to make sure that the employee is fit and able to carry out work tasks without any risk to their health and safety of that of other employees (Kloss 2010). Murugiah (2002) indicates there are four frameworks to be considered in assessing fitness to work such as, personal attributes, work characteristics, legal aspects and work environment (see appendix 3). These frameworks should be used by the OHN in order to assess Gloria more completely, to ensure a holistic assessment and to take into account the needs of both the employee and business. Cox et al (2007) specifies that a general framework should be incorporated which takes into account features relating to the job. Murugiah (2002), four framework stated earlier was all addressed throughout Gloria’s consultation. When Gloria’s assessment was held she agreed with the OHN to share information regarding her condition with her manager. Gloria signed a consent form in order for the information to be released. Her medical records were securely stored in order to gain knowledge to medical history, continuity of care and to maintain medical records. The Data Protection Act 1998 (RCN 2005) under the Section 2 indicates any sensitive data for which consent is required, needs processing, meaning obtaining, in-putting, storing, using, disclosing of record. Gloria also signed her medical records as attestation of true account of events, as this can be used or required for legal context. With regards to Personal attributes she was currently employed as train driver and her medical / sickness history had no link to her current medical condition and her previous low sickness rate was duly noted. Her willingness to carry on working and not requesting immediate medical attention shows her positive attitude towards life and work. However, ignoring her present medical condition and returning to work early might result in a longer period off work, should the sprain not fully heal. HSE estimated that in 2004/2005 over 2 million employees in UK were suffering from illness which was made worse by work. Sickness absence is estimated to have cost UK economy around £12 Billion in 2004 Cox et al (2007). She was referred to physiotherapy by her local GP and an ultrasound scan of her ankle was also done, indicating that her sprain ankle required longer time to heal fully. The OHN noted all the recommendations given by all the medical practitioners involved in Gloria’s medical treatment. As Gloria was currently attending physiotherapy, it would be unwise for OHN to ignore this aspect of her treatment, coupled with the ultrasound scan indicating a soft tissue injury, which might take between 2-8 weeks to heal (Wright et al 2012). The DOH (2011), emphasise on the importance of collaborative working as patients are able to get the appropriate care needed from joint decision. The OHN collaborated the physiotherapist with the plan of embarking on lower limb class to facilitate final return to full duties, which was agreed by Gloria. As noted earlier, Gloria was prescribed co-dydramol 10mg/500mg and diclofenac sodium 50mg (appendix 4) for pain relief, which she finds helpful. Side effect of co-dydramol includes drowsy, dizziness or lightheaded and difficulty in sleeping (appendix 4) these symptoms can impact on the health and safety of Gloria and the general public hence, why she was not fit for present duties as her role is safety critical. The communication between OHN, and the manager was via written report regarding Gloria’s fitness to work, as well as all advice taken into account, the business needs and her activity of daily living. In accordance with the company’s policy and procedure, alternate duties are encouraged as a phased return to work for long term sickness absence. The assessment included the factors affecting Gloria, with regards to her ankle injury on both home and work in order for the OHN to give advice holistically (Kloss 2010). Not only was Gloria not been able to carry out her task at work, simple things at home have become very difficult due to pain, inability to walk without the crutches and swelling on her ankle coupled with the pain emanating from putting weight on the affected ankle. The OHN did not visit Gloria’s workplace; because she was familiar with the role of train driver from other visit. Furthermore, Lewis & Thornbury (2010) recommends that OHN’s should take a workplace visit to ascertain employee’s role, in order to plan safe phased return to work. These are in line with the framework, work characteristics and work environment. Furthermore, Health and Safety at Work Act (HASAWA) (1974) section 2, indicates the duty of employers to protect the health and safety of its employees as far reasonable practicable in accordance with the legal aspects of the framework (Stranks 2006). Employees as well have duties under Section 7 and 8 of the HASAWA 1974 to “take reasonable care” of their own health and safety and safety of others, to co-operate on any matter of health and safety and to do nothing that will endanger the health and safety of other employees (Stranks 2006). In Gloria’s case this could impact on the general public since her work tasks involve operating a train from conveying passengers, this in line with Section 7 and 8 of HASAWA 1974 (Stranks 2006). Employment is a huge aspect of most workers lives, as it provides people with a sense of dignity, purpose, developing new skills and knowledge which can only boost individual confidence and self-esteem (Kloss 2010). The manager maintained regular contact with Gloria until her full return to work in order to give support and stop her from feeling isolated. Gloria could also improve her condition and her return to work fitness requirement by doing basic things like, putting ice on the affected ankle, elevating the ankle, resting and protecting the ankle. All these were noted and a review sent to Gloria’s manager. At Gloria’s second fitness- to-work review, she appeared to be making slow but steady progress with regular physiotherapy treatment. She was still in pain, but well controlled with use of pain relief, she also as low exercise tolerance due to lack of sleep. Gloria indicated she wanted to go back to work but she was informed it was too early to consider such by the OHN, as her injury was still having a big impact on her activity of daily living. At a prior assessment with OHN Gloria had found it challenging getting to the venue of the assessment and it was noted that it was dangerous as it could potentially caused further injury to the affected ankle, as her Physiotherapy letter had stated (see appendix 5). It was agreed with Gloria that at a later date all options would be explored that are deemed safe for her return to work such as alternate duties locally. This may include office –based role on a and level surface, as well as not working more than 4 hours with micro breaks in-between to prevent her ankle from swelling and stiffness, if risk assessment rules out any adverse impact on her wellbeing and of the other employees around her. Another review was set for 6 weeks from the date, where comparisons will be made between her progress and last review. At the 6 weeks review, Gloria’s condition had greatly improved. She was currently walking without the use of crutches and had been discharged from physiotherapy. Discussion took place with her regarding returning to work on reduced hours of 4 hours a day. On a level surface, without the excessive use of stair or walking long distance, and periodic breaks were also advised to reduce the risk of swelling of ankle. This was agreed and consented to by Gloria. It was also agreed that an alternative work role (office based duties) was the best option at this time. All of the above was noted and forwarded to Gloria’s manager, with a new review date set for 4 weeks time to assess Gloria’s progress. Chapter 4 4.0 Conclusion and recommendations The OHN dealt with the case effectively and efficiently, and touched on four frameworks applicable to this case study. The assessment included the use of the four frameworks, though they were not utilised in any specific order. However, each framework was used individually and appropriately to identify Gloria’s ability / fitness to work. However, it would have been beneficial if the 4 framework was utilised orderly, in order to have precise information. The referral was very informative with Gloria Job descriptions .Gloria’s fitness to work assessment was thorough and the medical evidence from her medical record at her initial assessment and subsequent reviews made it straightforward for the OHN to make a decision in relation ability to carry out her work tasks; and the subsequent decision to request an alternative role till next review. It was evident that Gloria was well informed and followed up throughout her recuperation, and she was actively involved in the assessment process. She agreed to the release of information to management, signed consent forms and attested that her medical records were a true account of events. Additionally, she received a copy of all documentation including reports to her employer. The OHN collaborated well with Gloria, her manager, and physiotherapy encouraging joint- decision making on how best to rehabilitate Gloria and safely accommodate her phased return to work. The OHN assessed Gloria’s physical wellbeing in relation to personal aspects in regards to her ability to perform work tasks and there were physical conditions that prevented her from performing those tasks. Legal duties of both the employer and employee were taken into account during the assessment and reviews (HASAWA 1974) as well as other Health and Safety Regulations. These were important as it might impact on the employer, other employees as well as passengers on the trains. The OHN did visited Gloria’s place of work in order to familiarise herself with the conditions she work under as well as the tasks involved in her role as a train operator, so that she can make her assessment accurately. In conclusion, Gloria’s fitness –to- work assessment was dealt with effectively and it resulted in Gloria returning to reduced-hour work (4hours a day) and a alternative role till she was fit enough to be return back to her original role as a train operator, when she is fully rehabilitated. The phase return to work was agreed by both Gloria and her manager, as it is aiding her return to work safely. It was within company’s obligation to provide Gloria with alternative duties. Words count- 4,139 References Adam et al. (2006) the Biomechanics of Back Pain. 2nd ed. London: Elsevier Ltd Bevan, S et al. (2007) Musculoskeletal Disorders and Labour Market Participation. London: The work foundation. 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