When work itself is rehab

There’s nothing like injury-enforced worklessness to highlight the importance of work for wellbeing. Virginia McMillan explores the journey through injury and the return to work, from the patient’s and vocational rehabilitation physio’s perspectives.

On holiday last December, and enjoying a dip at a pool complex dubbed Splash Planet, 43-year-old Jason Howse got a lot more than a few splashes. A large child spiralled rapidly out of a waterslide and slammed straight into him. Pulled from the water by his son, Jason could hardly move and pain shot through his spine. The timing was unfortunate. He had only recently recovered from a discectomy. That operation was required after a serious fall he sustained in 2012. While awaiting surgery he was introduced to physiotherapist Claire Sanders by his ACC case manager.

Claire is a vocational rehabilitation coordinator with TBI Health in Lower Hutt. It became her job to design a recovery plan to prepare Jason for return to work as soon as possible. The patient came via an ACC’s “Stay at Work” contract. ACC explains that Stay at Work provides “a three-stage service which addresses the spectrum of injuries, and matches these needs with an appropriate level of service”.

The stages are early return to work (for shorter duration or less complex situations); graduated return to work (longer duration, more complex); and continued interventions (further, ongoing support).

Jason was keen to get back to work but wasn’t sure what he should or shouldn’t be doing, particularly as he was troubled by leg pain. The programme designed by Claire was fine by him and, importantly, agreed by his doctors and his employer. Jason has been a window-cleaner for 14 years, a job he admits is physically demanding.

Within two days of meeting Claire, he found he could return to work a few hours a week; his boss had agreed he could do administration work only. Jason also began an exercise regime in the TBI Gym, under the guidance of physio Rodney Ford.

This helped him build strength prior to the discectomy that was eventually carried out in April 2013. Jason says compared with a previous, similar operation, he felt little pain after the surgery and stayed for two days in hospital, rather than five. Next, he rebuilt strength, range of movement, flexibility and cardiac fitness and practised for the hard grind of window-cleaning. He found this valuable preparation for getting “back on the tools”.

The range of equipment in the TBI gym ensures patients can rehearse many of the same movements needed in manual jobs. Using pulleys, Jason mimicked the upper-arm and shoulder stretch he needs for using window cleaning extension poles. Jason says he healed quickly. He continued some of the gym exercises at home and walked for an hour most days. Within three weeks of the discectomy, he had returned to the admin role and within three months, was able to start gradually building up to full-time window-cleaning. Jason says he was washing those three-storey buildings again and “good as gold” – but then came the waterslide accident.

After that, because he had been through it all before with TBI, he says he “knew what to do to keep active: it was far easier”. Again, Claire came up with a rehab plan. This time, his surgeon prescribed a steroid injection rather than surgery.

After a break of two weeks for the injection site to settle, Jason was back in the gym. Within another week, he could go back to work for a few hours a week this time, as a supervisor. Jason is once again an active member of the window-cleaning team, working five hours a day five days a week.

His rehabilitation plan still has him attending the TBI gym three times a week. Sessions are now generally 40 minutes long and include the treadmill, stretches, leg slides, back extensions, dumbbell lifts, and squats. He still walks regularly and also uses the Swiss ball at home.

“As I’ve got stronger, I’ve been increasing my use of the work tools and upping my work ethic, and the boss is really happy,” Jason says. He wears a back brace “when I know it’s going to be strenuous,” he adds. He aims to be fully employed and off ACC by the time his surgeon signs him off – hopefully, next month. Jason says he appreciates the help he has received from TBI and ACC.

That’s all part of the job for Claire as a coordinator, who liaises between the patient, their employer, ACC case manager, medical specialist, GP and physio, and other therapists where relevant. Getting a clear picture of the patient’s injury and the tasks and requirements of their job involves a lot of questioning, listening and functional assessment, and visiting the patient’s workplace.

Claire says it’s crucial she understands what the patient can safely do postinjury, compared with the job’s demands. She says the aim is a return to the patient’s pre-injury ability to handle the job, via medically appropriate therapies and a graduated return to work. Sometimes, function at exactly the same level as previously won’t be achievable, and ongoing job changes need to be negotiated.

Jason says with  his first back injury, 10 years ago, he lacked the support he has experienced in the recent crises. Harking back to that earlier time, he had a much longer and more difficult recovery. He stayed at home for 10 months, on a range of strong medications. Now, he keeps to two mild painkillers and carefully limits doses.

Pain wears you down, says Jason. Before he restarted regular exercise, he would sometimes get snappy with his partner and would feel “on the shelf, and useless”. “The money side of things is stressful, “he adds. Finances, relationships, self-esteem and confidence can all take a knock when injury strikes.

The Australasian Faculty of Occupational & Environmental Medicine comments:

  • Activity is an integral part of rehabilitation and should be prescribed;
  • Provision of modified duties fosters return to work;
  • People are best off when they return to productive work in a supportive environment; and
  • Return to work is more likely to be successful when undertaken early.

The faculty also says modified duties have been shown to halve the reduction in time off work. Workplace contact by the health professional, and the patient’s expectation of success play a major part in successfully reintegrating back into a job.

Claire sees the reality of these findings in her work every day.

“It’s hard to get work fitness and work toughness back when you’re not on the job,” she says. She emphasises to patients the value of work and the importance of a positive attitude, and lets them know they will be supported throughout, by both their rehabilitation case manager. Some patients need encouragement or referral to a psychologist or other health professionals to help them overcome emotional obstacles to venturing back to work.

"It’s hard to get work fitness and work toughness back when you’re not on the job"

− Claire, Vocational Rehabilitation Coordinator, TBI Health Lower Hutt