Author: Dr Tony Williams, Consultant Occupational Physician, Working Fit Ltd.
Date: August 2015.
We must always consider three aspects of fitness after surgery. These are what the person can do, what they are safe doing, and what they want to do.
The first, what they can physically do, will depend on their physical and physiological state. They may be so weak they cannot get out of bed, they may have a cast on the leg so cannot walk, they may have poor vision so they cannot see or read. Their physical capability will affect what they can actually do and how long they can do it for. It may reflect their physical fitness prior to surgery, or body function after surgery. Their intestines may not function for several days, if they have their thyroid removed it may take weeks for them to settle on a physiological dose of thyroxine tablets, if they have their pancreas removed it may take months to settle on medication. It is usually possible to assess physical capability objectively.
A person may be safe returning to work within a day of a mesh repair of an inguinal hernia (Amid et al., 1993). They will, however, usually experience substantial pain if they do so, and heavy lifting may well remain painful for several weeks afterwards. Is it reasonable to expect an employee to endure pain, and if so, how much?
The second, what they are safe doing, will depend on the effects of medication, physical weakness or altered limb function, fatigue, altered vision, altered hearing or the impact of pain on concentration. Some objective assessments can be made for safety, but some subjective assessments will be required, particularly in relation to fatigue and pain.
The third, motivation, is much harder to assess and manage. Employees who don’t like their job, line manager or colleagues will be more reluctant to return to work. Where they believe they will be harmed by work they will have less confidence in returning. Some will see an opportunity to stay at home for childcare reasons during school holidays or to care for an elderly relative. Occupational health providers may well help identify relationship issues and motivational issues, tailoring their advice to the specific situation.
Surgery can represent a very significant event in someone’s life. It may be a very positive event long anticipated, such as hip replacement, or a very negative event, such as bowel resection and stoma formation, or limb damage after trauma. Recovery can depend substantially on the attitude of relatives, friends and medical practitioners. Expectations and beliefs can help or hinder recovery. Inappropriate and unhelpful beliefs can be reinforced by inappropriate medical advice about recovery, in particular about eventual capability. Doctors often advise patients they will never work in their former occupation when it was physically demanding, even though the evidence shows otherwise.
Inappropriate beliefs and behaviours, often called ‘yellow flags’ in occupational health practice, must be identified and addressed before planning a rehabilitation programme back to work. A phased return to work is often needed primarily to help the employee regain confidence rather than to address physical capability or safety. It is important not to be judgemental, and to accept that different employees will have different needs. Where there is a substantial variance between what the employee feels capable of doing and what should actually be reasonably possible, this will need to be addressed by management.