Case reports

1. Case reports Ari Kaukiainen Seminar on Work Ability 04.12.2003 Kaukiainen FIOH 2003

2. Questions and instructions for group discussions Task I: Consider the background legend of the case. Please, think about the following questions: • Major problems restricting ability to work? • Could you meet problems like at your practice? • How would you assess ability to work? • Which consultations / tests are required? • Possibilities for medical / occupational rehabilitation? There are no right or wrong answers to these questions! You can choose your consultation / test resources according your free choice. Kaukiainen FIOH 2003

3. Case reports • Task II: You are then given results from the comprehensive work ability assessment done • Please, criticise! • How was the assessment done? Do you agree with the final opinion? Kaukiainen FIOH 2003

4. Case 1: A 32-year-old female office worker • The patient was on a sick leave due to anxiety and depression and problems of previously operated lower back. • The problems of lower back had started as ischias like symptoms 4 years ago. An L IV-V prolapse was operated 2 years ago with good results. Some months after operation she had a minor accident where the back pains and ischias symptoms started again. Magnet resonance imaging (MRI) was then done. No stenosis or discusproplapse was found. LIV-V protrusion was seen. No instability was found in X-rays. No sign of acute ischias was to be found in ENMG. Conservative rehabilitation was recommended. Kaukiainen FIOH 2003

5. Her general practitioner referred her to a psychiatric policlinic because of depression. Besides of backache there was tiredness and sleep problems. Diagnosis was mixed depression/anxiety disorder. SSRI-antidepressive medication was started and a phychoterapeutic session was recommended. She was not yet willing to start therapy. • When work ability assessment process started the patient felt problems with walking, sleeping and sitting down because of lower back. Ischias symptoms still present. Maximum walking distance between 0,5 - 2 kilometres. Concentration difficulties. There had also been sad events in personal life. Her goal was to be able to return to her office work. Kaukiainen FIOH 2003

6. Case 1: A 32-year-old female office worker Results from the comprehensive work ability assessment • The main problems at the start point were defined as previously operated back and current problems with mental health. Copies of previous medical records were acquired. • A specialist in occupational health / medicine was consulted, as well as an orthopaedist, physiatrist and a psychiatrist. A psychological examination was done and the patient met a social worker. Laboratory tests. MRI of the lower back had been done recently elsewhere. Final opinion was decided in a case meeting with the specialists participating. Decisions and recommendations were then discussed with the patient before the statement was written. Kaukiainen FIOH 2003

7. Case 1: A 32-year-old female office worker Summary of results II • Work history in office work was rather unite with exception of sick leaves because of back problems. She had a three-year education for her occupation. • Laboratory tests included control of inflammatory parameters and some common exclusion tests often used with depression. All were within normal limits. • Orthopaedist: No indication for re-operation. There has been a new distorsion injury in a previously operated back resulting in chronic pain. Intensive rehabilitation is required to control pain, improve moveability and to train muscular force of both belly and back. Kaukiainen FIOH 2003

8. Case 1: A 32-year-old female office worker Summary of results II • Physiatrist: No clinical sign of acute ischias. An intensive rehabilitation course is recommended in near future. While waiting for the course, the patient will start a personal training program. Prognosis of backache and work ability is good. • Psychologist: The patient has had many set backs in personal life during the last years. Besides somatic health problems there has been anxiety and depression. However, she has gained some new energy recently. According to tests done her cognitive capacity is good. • Psychiatrist: The patient has slight to moderate depression because of long-term pain. She also has tendency to anxiety with some features resembling panic disorder. SSRI-antidepressive medication is further recommended. The present state of mental health affects her work ability, but backache is the primary concern. Kaukiainen FIOH 2003

9. Case 1: A 32-year-old female office worker Summary of results III Work ability / overall statement and recommendations: • The patient was referred to an intensive rehabilitation course with a start in near future. After the course she can continue training under supervision in a health centre physiotherapy unit. She will also be in contact with a mental health clinic and continue her medication. In case her present antidepressive medication is not good enough, it will be changed. • The prognosis to continue in her work was good when rehabilitation would be in progress. It was estimated that after 3 months she could return to office work. Kaukiainen FIOH 2003

10. Case 2: A 53-year-old male construction worker • He had a bimalleolar fracture of left ankle one year prior to investigations. The fracture had been operatively fixed with fixing material well in place. Sick leave ever since. He was referred to comprehensive work ability assessment. • General practitioner had proposed disability pension because of asthma bronchiale, type 2 diabetes mellitus and hypertension. • The patient had no occupational training/degree. He had worked in various jobs before becoming a construction worker 10 years ago. • He had a regular asthma medication for last 5 years. Asthma had been rather well in balance. No major falls in pulmonary functions. Medication was improved when he visited a pulmonary clinic recently. Slight restriction in spirometry was found and a PEF-follow-up was between 450 - 500 l/min, no improvement with bronchiolyte. Kaukiainen FIOH 2003

11. Medication for hypertension for 6 years. Blood pressure measurements between 130-190/85-110. Medication for type 2 diabetes for one year with fB-glucose in balance between 7-8. • Exercise testing prior to investigations was not susceptible for cardiac ischemia. Physical condition was not good. • Overweight (BMI 36), no smoking history, and no use of alcohol. • When work ability assessment process started the patient experienced still difficulties in walking with limping of left foot, pain in ankle region and in toes. There had been very little physical exercise during last year. Some pain even in left shoulder, left thumb and left knee. Able to walk only shorter distances, difficulties in bending down. Even dyspnoea restricts faster walking. The patient felt that he could not cope with his work because of stiffness, dyspnoea and impaired physical condition. Kaukiainen FIOH 2003

12. Results from the comprehensive work ability assessmentsCase 2: A 55-year-old male construction worker • The main problems at the start point were defined as dyspnea, impaired physical condition and stiffness and other problems of locomotor system. Copies of previous medical records were acquired. • A specialist in occupational health / medicine was consulted, as well as a specialist in pulmonary medicine, orthopaedist, physiatrist and a specialist of internal medicine. A neuropsychological examination was done. Respiratory function tests included spirometry, spiroergometry and histamine challenge. A two-week PEF-follow-up was done. X-rays from knees, left ankle and left foot. Laboratory tests. Final opinion was decised in a case meeting with the specialists participating. Decisions and recommendations were then discussed with the patient before the statement was written. Kaukiainen FIOH 2003

13. Case 2: Summary of results I • Work history consisted of various jobs before the patient started as a construction worker 10 years ago. Despite of many different jobs there has not been any longer periods of unemployment. His present job was physically rather demanding including working on knees. • Laboratory tests were done including B-La, B-Hb, MCV, B-Leuk, fb-Gluk 8, S-CRP, fS-Krea, S-ASAT, S-ALAT, S-GT, S-AFOS, S-TSH, S-T4V, fs-Kol, fs-Kol-HDL, fs-Kol-LDL, fs-trigly 2,3, HBA1C 7,0, S-K, fs-CA, S-Urathe, S-CDT. Urine was clean. X-rays: • Knees: Slight arthrosis in both knees. • Left ankle and foot: Bimalleolar fracture well healed and position correct with fixing material in place. No clear arthrosis. Minor calcaneal sporn. Possible diffuse osteoporosis. Kaukiainen FIOH 2003

14. Case 2: Summary of results II Respiratory function tests: • Spirometry: Slight restriction (obesity?), no obstruction. No clear bronchodilation effect. • Histamine challenge test: No bronchial hyperreactivity. • Spiroergometry: Wmax/min was moderately impaired (60 % of age- and size-adjusted reference value). The test ended because of subjective tiredness. No chestpain or dypnoea. No diagnostic ischemic changes in ECG. No arrhythmia. RR slightly hypertensive both in rest and in exercise. Oxygen saturation normal. No diagnostic cardiovascular abnormalities. No reaction of asthma during exercise. No hypoxemia during exercise. Maximal oxygen consumption decreased. Breathing reserve normal. Possible mechanical hypoventilation due to restricted movements of thorax. Summary: The overall finding is probably due to impaired physical condition (=not enough exercise). Obesity and slight restriction had their influence on results. Kaukiainen FIOH 2003

15. Case 2: Summary of results III • PEF-follow-up (2 weeks) was done during sick leave, medication continued. No major variation. Specialist in pulmonary medicine: • Asthma medication has not been good enough. However, some changes were made at a pulmonary clinic before our investigations started. Present asthma status is stable. Asthma restricts work ability in dusty and physically demanding work, but does not alone make the patient unable to work. Overall statement has to be considered together with opinions from other specialists. Kaukiainen FIOH 2003

16. Case 2: Summary of results IV Specialist in internal medicine: Hypertension is not in balance, now 160/100. Results from spiroergometry are even worse than one would expect considering asthma and obesity. There is a suspected sign old cardiac infarct in ECG. Coronary angiography is recommended. It seems that work ability is decreased in physically demanding jobs. Orthopaedist: The bimalleolar fracture has healed well in place. No clear orthopaedic work ability restrictions. Physiatrist: There is still some restriction in movements of left ankle to be found and the ankle is slightly painful under load. Knee arthrosis is not yet a work ability problem. There are no current back problems. The work ability is restricted to current work. The patient is recommended to a health centre physiotherapists for guidance sessions. Psychologist: The patient is not depressed. The possibilities for occupational rehabilitation (new work) are not good due to cognitive capacity. Kaukiainen FIOH 2003

17. Case 2: Summary of results V Work ability / overall statement and recommendations: • The patient was referred to a cardiological policlinic for further cardiac evaluation. The need for evaluation is not acute and probably the patient has to wait some months. The follow-up of diabetes and hypertension and rehabilitation of ankle are best done by the local general practitioner. • The patient is considered to be unable to his work for one year (Morbus ischemicus cordis susp., Asthma, Diabetes, Hypertension, St. p.fractura bimalleolaris cruris, Obesity, Gonarthrosis l.a. incipiens). His work ability has to be evaluated again after cardiac evaluation and rehabilitation. Kaukiainen FIOH 2003

18. Acknowledgements Part of the presentations are based on earlier seminar on Work Ability in Tallinn 2002, held together with Dr Heikki Frilander, specialist in occupational health and occupational medicine Kaukiainen FIOH 2003