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What do we know about how patients return to work after hip and knee replacement surgery?
Everyone is different and as a result everyone’s experience of returning to work will be different. To highlight just how varied the return to work process is and give you an idea of what is ‘normal’ we have provided some information from patients questioned as part of the OPAL study:
The size of the problem:
· 1 in 4 (25%) of patients undergoing hip or knee replacement were in work prior to surgery and intended to return to work after surgery.
Time taken to return to work:
· At 16 weeks after surgery 7 in 10 of the patients that responded to our questionnaires had returned to work. Of those patients that returned to work a quarter had done so by 7 weeks, half by 10 weeks and three quarters by 13 weeks. In some cases patients had not returned to work by 24 weeks demonstrating that for some individuals it may take more time.
· There was no relationship between the type of work a person undertook and the time that they returned to work. Patients in physically demanding jobs took the same amount of time as patients in more sedentary occupations.
Work circumstances prior to surgery:
· Overall a quarter of people attending hospital for hip and knee replacements stated that they were in work and intended to return to work after surgery.
· 4 in 10 (40%) were in full time employment. Of the rest 1 in 4 (25%) were in part time employment, 1 in 4 (25%) were self-employed and 1 in 10 (10%) were working as volunteers or carers in unpaid roles.
· As part of their job just under a quarter of people worked rotating shifts and almost a half were required to drive while at work.
· A half of people questioned felt their job was physically demanding.
· 7 in 10 (70%) patients reported that they had to drive to get themselves to work.
· Overall almost 9 in 10 (90%) of people were working in their usual job and job role right up to their last day at work prior to surgery. The majority of people continued to work right up to the week before their surgery.
Return to work after surgery:
· People who return to work do so in a variety of ways. Whilst 5 in 10 (50%) of people returned to work doing their usual hours and duties, 4 in 10 (40%) returned to work on reduced hours and 1 in 10 (10%) returned doing altered duties.
· 3 in 20 (15%) of people reported that adaptions or changes were made to the workplace to help their return to work and 7 in 20 (35%) reported that adaptions or changes were made to their pattern of work.
Who can help patients with their return to work?
If patients are having a problem or they wish to discuss their return to work with someone other then the return to work coordinator we suggest that they try and contact one or more of the following:
1) Their line manager
2) Their occupational health department (if they have access to one)
3) Their human resources (HR) team
Alternatively advice can be sought from the:
· Fit for work service https://support.fitforwork.org/
· Fit for work Scotland https://fitforworkscotland.scot/employees/
· Citizens advice bureau or ACAS (for issues with sick pay and employment rights)
· Access to work scheme https://www.gov.uk/access-to-work (for employees having prolonged problems returning to full time normal work).
Occupational Health departments
Many employers are supported by occupational health providers that can be an additional source of help and support. While the vast majority of larger employers have such a service (this might be in-house or out-sourced), not all employers provide, or have access to, occupational health. It is worth checking with the patient whether their employer has access to an occupational health service and if so how this service might be accessed.
Occupational health teams provide a variety of help and information that could help patients return to work. This includes providing advice about:
· Safe working practices
· Ergonomics (studying how you work and how you could work better)
· The management of sickness absence
· The need for workplace health assessments
· Health promotion and health education
Helping patients preparing for a meeting with their employer
Patients may feel apprehensive and anxious about discussing their health issues. It can be difficult. Worries over redundancy or forced ill-health retirement can prevent some people from being open with their employer. However, it is against the law for a person to lose their job because of a chronic illness or a need for treatment.
There are good reasons for patients to be open and honest about their situation with their employer:
· It might make it easier to get time off for medical appointments if their employer knows about the problems you are having
· If their employer is aware of their circumstances then it will help them to understand their needs.
· Their employer, and co-workers, will know what to do if they have a medical emergency
Patients should be encouraged to prepare what they are going to say and how they are going to explain their needs before they speak to their employer. Patient should follow the steps in the patient workbook that will help them to organise and document their problems. This will enable them to talk to their employer with confidence about the problems they are having at work, the problems they think might impact on their ability to return to work, the modifications and adaptions to their place, type and pattern of work that might be needed to help them return after surgery, and their expected period of absence after surgery. Remember employers do not necessarily know about this type of surgery and how best to facilitate a return to work for their employees.
How can fit notes help patients return to work?
We know that people do not always need to be 100% fit to be able to return to work. The fit note can help patients return to work after hip or knee replacement by looking at what they can do rather that what they can’t. The fit note allows the doctor to make recommendations about adjustments that could be made to a patients work to allow them to return sooner than would otherwise be the case.
The surgical team should provide the patient with a fit note before they leave the hospital after their operation. They should do this based on the return to work plan the patient developed in their workbook. The surgical team can then provide them with a fit note of suitable duration and that corresponds to their needs by recommending a phased return, amended duties or workplace modifications. If the patient needs a further fit note then this is usually provided by their G.P. If you attend their G.P surgery for a fit note after surgery we advise they take their workbook with them so their G.P can see their return to work plan and compare this to their recovery after surgery. This information will help the G.P provide them with a fit note that matches their needs.
Expected recovery after surgery
When thinking about post-operative recovery after surgery we advocate using the excellent resources provided by the Royal College of Surgeons of England. They can be found at:
Hip Replacement: https://www.rcseng.ac.uk/patient-care/recovering-from-surgery/total-hip-replacement/recovery-tracker/
Knee replacement: https://www.rcseng.ac.uk/patient-care/recovering-from-surgery/total-knee-replacement/recovery-tracker/
Useful exercises to help patients recover after surgery can be downloaded as a PDF from the Arthritis UK website:
Hip Replacement: https://www.arthritisresearchuk.org/arthritis-information/surgery/hip-replacement-surgery/what-about-sport-and-exercise.aspx
Knee Replacement: https://www.arthritisresearchuk.org/arthritis-information/surgery/knee-replacement/what-about-sport-and-exercise.aspx
Post-operative considerations for return to work
Many surgeons do not impose restrictions on patients after hip or knee replacement. As long as the patient is sensible it is usually safe to return to most activities when they feel able to within the first 4-6 weeks after surgery. The general rule is that ‘if it hurts then don’t do it’. Having surgery is painful and they will be sore, especially for the first few weeks. This is normal. As they recover certain activities may cause additional pain and discomfort. If they do this is the body’s way of telling them to slow down. If this happens they should be advise not to push or overdo things, they should leave that activity for a few days before trying again when it becomes more comfortable to do so.
While the majority of surgeons do not impose restrictions on recovery some may still advise avoiding certain activities for the first 6-8 weeks. It is useful for the return to work coordinator to understand any local policies and procedures regarding post-operative recovery that might apply to their patients.
Some of the restrictions used by surgeons that may be relevant to the workplace and are described below:
For patients undergoing hip replacement the surgeon may advise the patient to be aware of the following to minimise the risk of your new hip dislocating:
· Avoid bending the hip more than 90° (a right angle) during any activity – This can be an issue if the patient sits in a low chair for work or spends time on the floor or in tight or confined spaces.
· Avoid twisting the hip or swivelling on the ball of your foot – Be conscious of turning quickly as can sometimes happen in a busy work environment.
· Don't cross legs over each other while sitting at work.
· Wear sensible and supportive outdoor shoes
· Don't force the hip or do anything that makes the hip feel uncomfortable – This applies to all activities in all jobs.
For patients undergoing knee replacement the main risks relate to the new knee joint becoming swollen and painful if they do too much or stiff if they do to little. Some useful tips include:
· Keep up exercises even when back at work. Make time in the work schedule to complete exercises each day. This will help prevent stiffness and help to strengthen the muscles around the new joint.
· Avoid twisting the knee or swivelling on the ball of the foot – Be conscious of turning quickly as can sometimes happen in a busy work environment.
· Wear sensible and supportive outdoor shoes
· Try not to rest for long period with the knee bent. Move regularly and straighten the knee. Getting the knee straight is as important, if not more so, than getting a good bend!
· Avoid kneeling on the new knee for the first 4-6 weeks. When the patient doe kneel they may find that kneepads or cushions help to make it more comfortable. Unfortunately not all patients feel able to kneel after a knee replacement. We suggest that if kneeling is important to their work this is highlighted this to their surgeon before their operation.
Driving after hip and knee replacement surgery
Many people drive to work and a significant number of people also drive as part of their usual job role. The OPAL study found that 75% of patients reported the need to drive to get to work and 40% were required to drive whilst at work. It is therefore important for people aiming to return to work to get back driving as early as possible following their surgery.
Before resuming driving, patient should be fully recovered from their surgical procedure. They should be free from the distracting effect of pain and the effects of any pain relieving medication they may be taking. They should be comfortable in the driving position, be able to safely control their car and must be able to perform an emergency stop with a normal brake reaction time. Brake reaction times return to normal approximately 2 weeks following a hip replacement and 4 weeks following a knee replacement. It may therefore be appropriate to return to driving approximately 4 weeks after surgery.
After hip or knee replacement, patients do not need to notify the DVLA unless instructed to do so by their doctor. However, they must tell DVLA if you’ve had an operation and they’re still unable to drive 3 months later. They can be fined if they don’t tell the DVLA about a medical condition that affects their driving and may be prosecuted if they’re involved in an accident as a result. Higher medical standards are required for those holding a Class 2 licence, so for reasons of safety their doctor may advise them to delay driving for a longer period. Patients should be encouraged to speak with their employer if they drive as part of their work role. Ultimately, it is their responsibility to ensure that they are in control of the vehicle at all times and to feel confident that they would be able to demonstrate this if required.
At 4-6 weeks after surgery, the patient might want to test their fitness to drive. They can do this by sitting in a parked car and applying pressure to the car’s pedals. If they experience discomfort they should probably wait a bit longer. They should only think about driving again when they can put enough pressure on the pedals to do an emergency stop. When they do start driving it is a good idea for them to go out with a friend or relative for a short drive at a time of day when the roads are quiet. If they plan to return to work but do not feel confident driving they may still be able to travel to work with family, friends or colleagues. It some instances their employer may be able to arrange transport for them and this is an option worth exploring if they are planning an early return to work.
How can employers help patients with their return to work?
Planning a return to work after surgery is difficult but it is made much easier if there is someone at the patient’s place of work that can help. This is why all patients are encouraged to contact their employer both before and after surgery and discuss and review their plans for return to work. There are a number of ways employers and work colleagues can help their employees (information taken from fit4work and fitforworkscotland):
· They should spend some time with their colleague and listen to the plans they have made. Employers should be open-minded about the potential benefits of an early return to work. An earlier return can be beneficial to the employer:
o It can reduce costs by reducing the need for someone else to cover the work.
o Nurturing employees and making them feel valued increases staff retention and reduces recruitment costs.
o An organisation’s treatment of its employees while off sick and returning to work can shape the way they and others regard the company. Employer support will create a positive culture and boost morale.
o Returning to work in a phased way reduces the likelihood of employees not returning at all, thereby saving the need to recruit and train a new staff member.
· Early engagement with their colleague is important. The way employees are treated while they are off work can impact on how they view the company, their colleagues and, ultimately, how successfully they return to work. Being supportive from the outset can reduce this impact. Early engagement also gives the employer plenty of time to plan and put in to action the plans they have made.
· Research has found that the actions and attitudes of the line manager can be crucial to a person’s successful return to work. Line managers can take a number of steps to improve the return to work process, including:
o Keeping in contact with absent employees whilst they are off work in order to keep them updated on the events at work;
o Meeting with absence employees before they return to work draw up a plan for their gradual return. This plan should include information about their duties and hours when they return and how these will increase over time. This is an integral step in the OPAL program (STEP 5)
o Being flexible with regards to duties and hours and adapting quickly if recovery turns out to be slower than expected;
o Remaining positive, flexible and understanding
o Utilising a phased or modified return to support early return to work
What is a phased or modified return to work and how can it help?
A phased or modified return to work involves returning to work gradually, often before the employee can undertake all of their usual work. This might include modifying the tasks they do at work or the number of hours they work. Implementation of a phased or modified return to work relies on an agreement between the employer and employee. Problems may occur with a phased or modified return to work if it is not arranged collaboratively and with the full agreement of everyone involved.
There are a number of different ways a phased or modified return can be achieved. The most common changes made to help people return to work after hip and knee replacement are:
1. Reducing the number of hours they work for the first few weeks.
2. Altering their pattern of work. This is can include altering shift patterns, avoiding specific work tasks (e.g. avoiding specific tasks that put excess stress and strain on their new joint), and reducing the pace at which they work (less productivity expected for a period of time as they ease themselves back into work).
3. Alterations to the workstation. This includes making changes to the layout of the work environment or adjusting / changing the equipment they use.
4. Undergoing additional training to learn new ways of working.
5. Improving accessibility and mobility. This includes making changes to access around the workplace for patients using sticks or crutches and parking arrangements to allow them to park nearer to their place of work.
6. Colleague support. The employer identifies someone to help and support the returner as they transition back to work after surgery or colleagues helping so patient can attend physiotherapy sessions or clinic appointments.
In the OPAL study 40% of people returning to work after hip or knee replacement did so doing reduced hours with a further 10% returned doing altered duties. Furthermore 15% of people reported that adaptions or changes were made to the workplace to help their return to work and 35% reported that adaptions or changes were made to their pattern of work. It is therefore extremely common for people to return to work on a phased or modified return.
The following are examples of how employees have been accommodated before/after THR/TKR taken from the OPAL study:
Reducing hours and altering patterns of work
· Planned and specified phased returns implemented over a period of weeks in order to ease the employee back into work
· Phased returns with amended duties with the employee returning initially on reduced hours and carrying out less physically challenging roles, such as cleaning staff not being required to carry out kneeling tasks
· Complex phased returns and altered duties to accommodate employees who do shift work and have non-standard working hours
· Informal phased returns which allow the employee to return at their own speed, giving them responsibility for their own return to work plan
· Where employees are working part time, a phased return is not always possible so duties can be made less onerous to compensate initially
· Using annual leave and public holidays in conjunction with a phased return to ease employees back into work without triggering sickness absence monitoring
· Implementation of less physically challenging roles such as an engineer using the computer to oversee the engineering work rather than carrying it out themselves or an employee being employed initially in a reception /administrative role
Alterations to the workstation
· Employers instigating a workplace assessment usually in conjunction with their occupational health practitioner, in order to assess the working conditions and equipment used by the returning employee e.g. risk and trip hazard assessment in a potentially hazardous workshop environment
· Workstation and seating assessment to determine optimum seat and desk heights for employees employed in office based roles
· Changes made to the equipment used to perform the work task e.g. the provision of lighter cleaning equipment such a light weight vacuum cleaners or backpack cleaners
· Maintaining existing equipment to render it as easy to use, for example oiling of wheels on trollies to make them easier to push
· Provision of seating e.g. provision of a chair to allow the employee to sit down during the day where their work role involves them spending most of the working day on their feet
· Providing a perching stool to allow standing work tasks to be done whilst supported
· Provision of an ergonomically designed office chair, with wedges and footstool where appropriate, following a workplace assessment
Additional training
· Training employees to develop alternative skills to allow return to work in a less physically challenging capacity, for example providing IT training for an employee in order that they might return initially to a more office based environment
Improving accessibility and mobility
· Allocated parking provided closer to the employees place of work
· Providing instruction and direction about specific work tasks e.g. that there should be no lifting of heavy items such as cash bags in a bank or post office environment or using lifts instead of stairs to access work areas
· Arranging taxis to allow access to the workplace for those employees unable to drive initially
· Allowing the employee to return to work in a supernumerary capacity initially until they feel able to return to their previous role
· Relocation to a different worksite closer to the employees home
· Working from home initially before return to the workplace
Colleague support
· Colleagues can be asked to provide support for the employee either informally by assisting with the carrying of heavy items, such as equipment or by covering aspects of the person’s job to allow them to start later in the day. Formalised arrangements can also be implemented with colleagues taking over the elements of the task that the employee finds most demanding following surgery, for example a teacher having the PE classes they teach covered by their colleagues for six months or a midwife only carrying out the aspects of the delivery that they feel physically able to manage, with colleagues on hand to step in where necessary.
LINKS AND CONTACTS
Links to local and national resources to help people return to work
Recovery after surgery
· https://www.rcseng.ac.uk/patient-care/recovering-from-surgery/total-hip-replacement/
· https://www.rcseng.ac.uk/patient-care/recovering-from-surgery/total-knee-replacement/
· https://www.nhs.uk/conditions/hip-replacement/recovery/
· https://www.nhs.uk/conditions/knee-replacement/recovery/
Fit for work services
· https://fitforworkscotland.scot/employees/
· http://www.workingfit.co.uk/orthopaedic-surgery-lower-limb
Driving after surgery
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