Background
Client was referred to the Occupational Therapist (OT) by the Occupational Health Physician for a base line assessment in view of carrying out a full Functional Capacity Evaluation (FCE) when she was well enough. Client had a six month history of symptoms of her condition which had resulted in her becoming absent from work. She was experiencing pain and a “burning” sensation in her legs as well as stiffness and pain from her elbows down to her hands. Her voice had also been affected. She was still awaiting a definitive diagnosis.
Initial Interview
A clinical interview was carried out with client in the Occupational Health Department. She reported that she could do small amounts of activity infrequently but stated that stiffness and pain in her legs prevented her from “pushing” herself. She reported that she was never free from pain but that driving, carrying items and being on her feet could make her symptoms worse. Client reported that she became sore when carrying out sustained postures or activities such as sitting, standing or walking. In contrast, use of ice, sitting with her leg supported, changing her posture and using a fan to cool the air down could improve the symptoms of her condition. Medication had improved her quality of sleep at night.
Client lives with her husband and 17 year old daughter in a 2-storey house. Her husband works full time as a consultant engineer. Client was independent with personal activities of daily living. She had adapted the manner in which she carried out tasks at home in order to be as independent as possible e.g. doing her shopping online as required. She was continuing to drive and stated that she found having cruise control in her car to be beneficial. She enjoyed swimming and walking.
Client qualified as a nurse in 1991 and had been working as a Community Psychiatric Nurse for 13 years. She worked full time and, as the service became a seven day service in August 2010, she worked approximately one in every five weekends. Client went out on a daily basis for routine visits to clients and in addition she carried out half a shift every fortnight on “crisis” duty where two members of staff worked together. She reported that she enjoyed the variety in her job.
Initial Actions
Client was provided with verbal and written lifestyle management advice by the OT which covered problem solving, pacing and energy conservation techniques. It was agreed that an FCE would be carried out when the client felt that she had reached an optimum level of functioning.
Functional Assessment
Six weeks after the initial interview, a four hour FCE was carried out in the OT Department. The purpose of the FCE was to assess the match between client’s present capabilities and the demands of her post as a Community Psychiatric Nurse.
By this time client was describing an improvement in the symptoms of her condition which she believed was due to medication prescribed by the Rheumatologist. In addition to attending the Rheumatologist, she had also had a course of Bowen Therapy.
During the FCE the OT utilised a number of assessments which included: Worker Role Interview; Pain Scales; EPIC Hand Function Sort; General Mobility Testing/Body Dexterity; Valpar Component Work Sample #9 – Whole Body Range of Motion; Valpar Component Work Sample #5 – Clerical Comprehension & Aptitude; Purdue Pegboard; Functional Lifting Capacity Test and Repetitive Movement Tests.
Through the Worker Role Interview, client reported that she felt confident that she could carry out all parts of her job. She reported that although she still experienced some discomfort in sitting, she knew how to manage her symptoms. She stated that her symptoms were not as frequent or extreme as before. Client believed she would require a graded return to work as she was still experiencing increased fatigue. She described a daily routine that incorporated a good balance of activity with rest periods. She had also been in to visit her workplace prior to the FCE and had been considering changes that she might have to make when she returned to work.
However, client’s self reports on the EPIC Hand Function Sort indicated that she may have been over-estimating her abilities. Her demonstrated ability during the functional lifting capacity test suggested that she was capable of work in the sedentary and some of the light demands categories for strength. This was a match for the day-to-day demands of her work as a Community Psychiatric Nurse as she was not moving and handling patients. However, due to the unpredictable nature of the patients she was working with there could potentially be instances where she was required to use Prevention and Management of Violence & Aggression techniques.
During the evaluation, client was able to demonstrate postures such as crouching and kneeling for short periods. Her tolerance for sitting and standing was still limited by pain but was at functional levels where she was considered likely to be able to sit for an hour long consultation with her patient without signs of discomfort.
OT Recommendations
Following the FCE, various recommendations were made by the OT for actions to promote client’s ability to safely return to her work duties with a reduced risk for aggravating her existing medical condition. These included:
• that for tasks involving manual dexterity client may require additional time as her pace of work may be slower than average;
• that prior to her return to work, a separate risk assessment be carried out, with regards the client’s ability to participate with the Prevention and Management of Violence & Aggression;
• that client should work in an area where she could vary her posture between sitting and standing on a regular basis to avoid the negative effects of prolonged static postures.
As her sitting tolerance was reduced, it was also recommended that client had a workstation assessment when she returned to work as her job entailed spending some of her working day carrying out administrative duties.
Follow-up
One month later the OT carried out a follow-up visit to the workplace following a request from client’s manager. The purpose of this visit was to assess the client’s work environment following her recent return to work. The objective was also to observe client performing her work duties to identify if there was any additional advice to be given or actions for work place modifications.
Client had returned to work three weeks before, initially for three half days per week. She had subsequently increased this to three full days. Although she was experiencing some fatigue on her return home from work she stated that this was “natural” tiredness. Client stated that she has been driving to/from her patients’ homes without difficulty since her return to work. In order to avoid driving in rush hour traffic she stated that she chose to arrive at work early.
During the visit to her workplace minor adjustments were made to client’s chair which should enable her to achieve the optimum seated position. As her feet did not comfortably reach the ground when seated she required the provision of a footstool which she could use as an alternative to the high stool that she had purchased. However other than the stool, she was advised to refrain from storing any items (such as files) underneath her desk.
It was recommended that client be supplied with a document holder on which to place written notes/files. The document holder would sit at the space between the keyboard and her screen to avoid client stretching from the shoulder (over her patient notes to reach the keyboard) and the effects that this has on her sitting posture and her upper back.
Finally, the OT recommended that client continue to make use of all measures to promote her own health and well being whilst at work. These include taking scheduled breaks, changing her posture regularly and avoiding sustained postures that may exacerbate her pain.