and Return to Work Expectations

crookedjourneyMechanics

Oct 24, 2013 (3 years and 7 months ago)

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Surgery, Recovery
and Return to Work
Expectations

GENEX Services, Inc.

Karyn Versteeg, RN, BS

OSIA Winter Conference, 2013

Carpal Tunnel Release



Generally,

an

incision

is

made

over

the

area

of

tendon

attachment,

the

tendon

tissue

is

cut

away

from

the

bone,

allowing

the

tendon

to

relax

or

pull

back

towards

the

muscle

belly
.



It

may

not

be

necessary

to

release

the

entire

tendon

to

decrease

tension

on

the

muscle

tendon

unit
.

If

the

tendon

is

to

be

reattached

(transposed)

to

another

location,

the

incision

is

larger

and

the

procedure

more

complicated
.



De

Quervain's

release

is

a

minor

surgical

procedure

accomplished

through

a

small

incision

exposing

the

tendon

sheath

(retinaculum)

along

the

thumb

(radial)

side

of

the

wrist
.

The

sheath

is

cut

(released)

around

the

two

tendons

at

the

base

of

the

thumb

and

portions

of

the

sheath

may

be

excised
.



The

release

is

done

under

regional

or

local

anesthesia

in

an

outpatient

setting
.


Recovery


Following

the

surgical

protocol

and

healing,

grip

and

pinch

exercises

are

introduced

between

2

weeks

and

4

weeks

postoperatively
.



When

the

tendons

can

tolerate,

more

strenuous

activities

are

introduced

after

6

weeks

postoperatively

to

restore

full

hand

function
.

Treatment

usually

is

completed

within

12

weeks
.



As

therapy

progresses,

exercises

should

be

reflective

of

the

work

environment,

which

must

be

reassessed

in

preparation

for

the

individual's

safe

return

to

work
.

An

ergonomic

assessment

may

be

indicated
.

Return to work


Job Classification


RTW Min/Max



Sedentary Work



1 days
-

3 weeks



Light Work



1

days
-

3 weeks



Medium
Work



1

days
-

3 weeks



Heavy
Work/



3 weeks
-

6 weeks



Very Heavy Work


Barriers


Cervical radiculopathy


Cervical spondylosis at C5
-
C6


Diabetes


Fluid retention with tissue swelling


High blood pressure


Hypothyroidism


Injury to the hand or wrist


Obesity


Renal failure


Rheumatoid
arthritis

Triangular Fibrocartilage Complex
Tears(TFCC)


The

central

portion

of

the

TFCC

has

no

direct

blood

supply,

large

central

disc

tears

do

not

heal

well

and

may

require

arthroscopic

surgery

to

trim

or

remove

torn

cartilage

while

leaving

the

support

ligaments

in

place
.



Wrist

arthroscopy

may

be

performed

under

general

or

regional

anesthesia

to

smooth

(
debride
)

or

remove

(excise)

unstable

fragments

of

cartilage
.

Peripheral

tears

of

the

cartilage

disc

may

be

repaired

with

stitches
.

Recovery


After

surgery,

the

wrist

is

immobilized

in

a

splint

for

2

weeks,

reassessed

for

healing,

and

then

re
-
immobilized

in

a

removable

splint

for

an

additional

4

weeks

to

allow

range

of

motion

exercises

to

begin
.



Strengthening

exercises

may

be

initiated

once

the

individual

has

regained

80
%

of

normal

wrist

range

of

motion
.



The

individual

may

return

to

sports

and

lifting

activities

at

5

to

6

weeks

post

injury

as

symptoms

allow
.


Return to Work


Job Classification


RTW Min/Max



Sedentary Work



1 week
-

2 weeks



Light Work




2 weeks


4 weeks



Medium Work



3 weeks
-

4 weeks






Heavy Work



4 weeks
-

8 weeks



Very Heavy Work


6 weeks
-

12 weeks


Barriers


Time delay from injury to procedure


Osteoarthritis


Rheumatoid arthritis


Diabetes


Vascular disease


Infection


Demand of job at injury

Rotator Cuff/Biceps
T
endon Repair


Several

different

surgical

procedures

are

used

in

repairing

the

rotator

cuff
.



One

procedure

involves

smoothing

(
debriding
)

the

ragged

edges

of

the

torn

tendon

and

suturing

the

tissue

edges

together
.



Often
,

the

end

of

the

tendon

must

be

reattached

to

the

upper

arm

(humeral

head)

as

well
.

If

the

gap

created

by

the

tear

is

too

large

and/or

the

tissue

too

stiff

to

be

pulled

together

again,

a

graft

may

be

necessary

to

cover

the

humeral

head
.



Alternatively
,

the

remaining

tendon

can

be

sutured

into

a

bone

trough

made

in

the

humeral

head
.


Recovery


As

the

pain

and

inflammation

ease,

treatment

aims

at

improving

strength

and

flexibility

to

the

shoulder

without

irritating

the

healing

tendon(s)
.



The

strengthening

exercises

begin

with

scapular

muscles
.

These

are

important

muscles

for

normal

shoulder

function,

and

the

exercises

can

usually

be

performed

without

excessively

stressing

the

healing

tendon(s)
.



Gentle

stretching

exercises

may

be

initiated,

avoiding

stress

on

the

healing

tendon(s)
.

As

the

tendon

heals,

strengthening

exercises

are

added,

as

indicated
.



Sling is worn for 4
-
6 wks to keep shoulder stationary

Return to work


Job
Classification


RTW Min/Max



Sedentary Work / Light
Work

1 week
-

3 weeks



Medium Work



4 weeks
-

8 weeks



Heavy Work/Very
Heavy
Work

8 weeks
-

12 weeks


*
Disability may be permanent if work


requires
arms overhead


Barriers


Age of tissue (not necessarily the age of the
patient)



Post
-
operative inactivity



Smoking



Dominant arm


Meniscus repair/
M
eniscectomy


Tears

along

the

inner

curve

of

the

meniscus

where

the

blood

supply

is

poor,

especially

those

that

are

of

the

ragged,

degenerative

type,

are

most

commonly

treated

by

removing

the

damaged

part

of

the

meniscus

(partial

meniscectomy)
.



Tears

near

the

outer

rim

of

the

meniscus

where

the

blood

supply

is

rich

may

be

repaired

with

stitches

(meniscus

repair)
.



With

either

procedure,

any

avascular

fragments

of

cartilage

are

removed
.



The

surgery

concludes

by

removing

the

arthroscope

and

tools

and

closing

the

small

incisions

with

sutures
.


Anatomy of the Knee

Recovery


If

a

meniscal

repair

has

been

performed,

extreme

flexion

and

rotation

should

be

limited

until

the

wound

in

the

meniscus

has

had

time

to

heal

(
8

to

12

weeks)
.



Knee

range

of

motion

exercises

can

help

to

restore

full

mobility

to

the

joint
.



Therapy

should

progress

to

strengthening

exercises

as

tolerated,

and

it

should

include

flexibility

exercises

throughout

the

period

of

strengthening
.



While

strong

muscles

around

the

joint

are

critical,

flexibility

of

the

same

muscle

groups

must

be

considered
.



Although

a

meniscus

can

heal

within

approximately

12

weeks,

the

joint

may

still

need

to

be

protected

from

heavy

loading

until

the

meniscus

has

regained

its

full

strength
.



If

a

meniscectomy

were

performed,

the

degree

of

knee

loading

during

work

and

leisure

activities

must

be

considered

and

discussed

with

the

physician

prior

to

return

to

work
.



Return to work (meniscus repair)


Job Classification


RTW Min/Max



Sedentary
Work



2 weeks
-

3 weeks



Light
Work



6 weeks
-

8 weeks



Medium
Work



8 weeks
-

12 weeks



Heavy
Work/



12 weeks
-

24 week


Very Heavy Work



Return to work (meniscectomy)


Job Classification


RTW Min/Max



Sedentary
Work



1 weeks
-

2 weeks






Light
Work



2 weeks
-

4 weeks



Medium
Work



2 weeks
-

4 weeks



Heavy Work/



4 weeks
-

6 weeks


Very Heavy Work






Barriers


Obesity


Female


Osteoarthritis


Synovitis (inflammation in the interior joint)


Amount of tissue taken (meniscectomy)


Ligament injuries


May increase rate of degeneration with time



Anterior Cruciate Repair (ACL)


The

ligament

is

reconstructed

by

taking

a

piece

of

tendon

from

a

different

part

of

the

body

or

from

a

donor

and

connecting

it

to

the

shinbone

and

thighbone
.



Although

there

are

different

methods

for

ACL

reconstruction,

they

all

involve

the

same

basic

procedure
.



An

incision

is

made

in

the

individual's

leg,

and

small

tunnels

are

drilled

into

the

bone
.



Then

the

new

or

harvested

ACL

is

brought

through

the

tunnels

and

secured

with

a

staple
-
and
-
buckle

system
.


ACL Anatomy

Recovery


Rehabilitation, requiring months of intense exercise,
is recommended for successful recovery from a
surgical repair of the anterior cruciate ligament.


Rehabilitation following anterior cruciate ligament
repair follows a structured process beginning
immediately after the surgical repair and ending
with the individual returning to work and other
activities.


The entire process can take up to 9 months.



Return to work


Job Classification


RTW Min/Max



Sedentary
Work



3 weeks
-

6 weeks



Light
Work



4 weeks
-

12 weeks



Medium
Work



12 weeks
-

24 weeks



Heavy
Work/Very Heavy Work

by report







Barriers


Females 2
-
8 times more likely for injury


Osteoarthritis in the joint


Arthrofibrosis (scar tissue build up)


Synovitis (inflammation of the inner joint cavity)


Obesity


Other knee injuries

Discectomy


A

discectomy

is

the

surgical

removal

of

herniated

disc

material

from

the

spinal

canal
.



The

discs

between

the

spinal

vertebrae

consist

of

a

gel
-
like

center

enclosed

in

a

fibrous

covering
.



A

herniated

disc

occurs

when

the

covering

is

damaged

and

the

gel
-
like

material

is

extruded
.



Discectomy

is

accomplished

either

by

direct

incision

over

the

affected

vertebra

and

underlying

disc

(open

discectomy),

through

a

small

incision

using

a

microscope

and

special

equipment

(microdiscectomy),

or

by

laser

(laser

discectomy)
.



The

surgery

includes

removing

fragments

of

the

disc

that

has

been

herniated

to

relieve

pressure

on

the

affected

nerve

root
.



Discectomy

can

be

performed

to

remove

cervical

discs

from

the

neck

region,

thoracic

discs

from

the

mid
-
back,

or

lumbar

discs

from

the

lower

back
.


Recovery


Usually

around

4

to

6

weeks

postoperatively,

patients

may

be

progressed

to

a

more

aggressive

exercise

program
.



Rehabilitation

should

emphasize

stretching,

strengthening,

stabilization

and

aerobic

exercises

as

well

as

instruction

of

proper

body

mechanics
.

Stretching,

strengthening

and

stabilization

exercises

should

focus

on

the

muscles

around

the

trunk,

hips,

and

thighs
.



Improved

general

aerobic

conditioning

has

been

shown

to

yield

better

postoperative

outcome
.

Low

impact

activities,

such

as

walking

and

swimming,

may

be

beneficial

after

discectomy

to

improve

general

fitness
.

Return to Work



Job
Classification


RTW Min/Max



Sedentary
Work



4 weeks
-

6 weeks



Light
Work



4 weeks
-

6 weeks



Medium
Work



6 weeks
-

10 weeks



Heavy Work/Very Heavy
Work

by report



Barriers


Alcohol

Abuse


Degenerative spine conditions (arthritis, ankylosing
spondylitis)


Infection


Inflammatory disease


Malnutrition


Nerve root damage


Obesity


Poor physical conditioning


Tobacco abuse

Laminectomy/Laminotomy


Laminectomies

and

Laminotomies

are

performed

under

general

anesthesia
.



The

individual

is

positioned

face

down

on

a

well
-
padded

laminectomy

frame

or

spinal

board
.

X
-
ray
s

may

be

taken

to

confirm

the

location
.



An

incision

is

made

in

the

middle

of

the

back

or

neck

over

the

area

of

involvement
.

The

muscles

beneath

the

skin

are

spread

apart

to

expose

the

laminae

overlying

the

spinal

cord

and

nerve

roots
.

Bone

is

removed

using

a

bone

cutter

or

air

drill
.



As

noted

above,

the

amount

of

bone

removed

will

depend

on

the

amount

of

exposure

or

decompression

necessary
.


Recovery


Outpatient

physical

therapy

begins

approximately

1

month

after

surgery
.



Modalities

such

as

ice

or

heat

may

be

used

to

reduce

pain

and

swelling

and

decrease

muscle

spasm
.

Increasing

range

of

motion

is

the

second

objective

of

rehabilitation
.



This

is

especially

important

due

to

the

prolonged

time

that

the

individual

wears

a

brace
.



Strengthening

and

conditioning

exercises

such

as

walking

or

swimming

to

increase

endurance

and

strength

as

tolerated
.



Therapy

also

addresses

correct

posture,

proper

body

mechanics,

and

ergonomics
.

Individuals

learn

strategies

to

sit

and

stand

in

positions

of

ease,

to

reach

and

lift

in

a

way

that

protects

the

back

and

neck,

and

to

pace

activities
.


Return to work


Job Classification


RTW Min/Max



Sedentary Work



4 weeks
-
6 weeks



Light Work



4 weeks
-

6 weeks



Medium
Work



6 weeks


8 week



Heavy Work/Very Heavy
Work

by report


Barriers


Obesity



Osteoarthritis



Prior spinal or abdominal surgery

Spinal Fusion


Spinal fusion is the surgical immobilization of two or
more adjacent bones of the spinal column
(vertebra).


Multiple
bones are fused or made to grow together
to become one solid bone.


For all types of spinal fusion, the segment of the
spine is ultimately immobilized with a bone graft,
which serves as a scaffold for new bone growth to
create a bony union between two or more
adjacent vertebrae.


For fusion to succeed, bone cells must develop into
mature cells that reproduce and grow throughout
the fusion matrix until new bone forms, fusing the
vertebrae together.


Recovery


A
pproximately

4

to

6

weeks

postoperatively,

or

when

recommended

by

the

surgeon,

isometric

training

of

the

trunk

muscles

can

be

initiated
.

General

conditioning

exercises

of

the

upper

and

lower

extremities,

and

aerobic

training

are

initiated

and

progressed

as

indicated
.



Activities

that

promote

trunk

flexion

should

be

avoided

until

approved

by

the

surgeon
.



Once trunk flexion is advised, then general trunk
flexibility, strengthening, and endurance exercises
can be taught and progressed as tolerated.


An ergonomic assessment may be beneficial to
modify the workplace as needed and ensure the
work status of the individual.





Return to work


Job Classifications


RTW Min/Max



Sedentary
Work


16 weeks
-

20 weeks



Light
Work



22 weeks
-

26 weeks



Medium
Work



26 weeks
-

32 weeks



Heavy/Very
Heavy
Work

by report



Steroid Injections


An

epidural

steroid

injection

is

performed

to

help

reduce

the

inflammation

and

pain

associated

with

nerve

root

compression
.



Nerve

roots

can

be

compressed

by

a

herniated

disc,

spinal

stenosis,

and

bone

spurs
.

When

the

nerve

is

compressed

it

becomes

inflamed
.



This

can

lead

to

pain,

numbness,

tingling

or

weakness

along

the

course

of

the

nerve
.

This

is

called

radiculopathy
.



The

goal

of

the

epidural

steroid

injection

is

to

help

lessen

the

inflammation

of

the

nerve

root

and

will

take

up

to

14

days

for

full

effect
.


The epidural space is located above the outer layer
surrounding the spinal cord and nerve roots. An epidural
steroid injection goes into the epidural space, directly
over the compressed nerve root.


Recovery


Follow
-
up

appointment

after

the

epidural

steroid

injection

is

likely

between

two

to

six

weeks

after

the

injection

to

determine

how

the

patient

has

responded

to

the

injection

and

if

they

have

any

continued

symptoms

from

the

nerve

compression
.



If

the

patient

continues

to

have

symptoms

or

if

they

return

after

a

period

of

time

they

may

consider

having

the

injection

repeated
.



Most

physicians

recommend

no

more

than

3
-
4

injections

during

a

year,

while

ODG

recommends

no

more

than

2

and

then

move

on

to

a

new

treatment
.

Return to Work


Job Classification


RTW Min/Max



Sedentary Work


1day


3 days



Light Work



1day
-

3 days



Medium Work



1 day


3 days



Heavy Work/



2 days
-

5

days


Very Heavy Work



Barriers


Leg
length difference greater than one inch


Obesity


Osteoarthritis


Osteoporosis


Rheumatoid arthritis


Scoliosis


Spondylolisthesis


Depression


Stress

Inguinal Hernia


Surgical

repair

of

an

inguinal

hernia

consists

of

either

an

open

or

a

closed

surgical

technique
.



The

open

technique

consists

of

opening

the

inguinal

canal,

reducing

the

hernia,

and

reinforcing

the

floor

of

the

inguinal

canal

with

a

synthetic

mesh
.



With

the

closed

technique
,

the

surgeon

uses

a

laparoscope

to

introduce

the

tools

and

mesh

through

puncture

holes

to

reduce

the

herniation

and

reinforce

the

posterior

wall

of

the

inguinal

canal
.



Heavy

manual

labor

workers

are

most

common

recipients

of

this

procedure
.

Recovery


Follow

up

occurs

1

week

after

surgery

with

limited

activities

until

that

time
.



Avoid

lifting

more

than

10

pounds

for

4

weeks

and

excessive

bending

or

twisting

for

1
-
2

weeks

following

surgery
.



W
alking

is

strongly

encourage

as

soon

as

possible

after

procedure
.

Successful

hernia

repair

is

achieved

by

reducing

factors

that

contribute

pressure

such

as

cough,

constipation,

and

repairing

the

defect

so

that

the

incision

line

remains

free

of

tension
.



Surgical

treatment

of

uncomplicated

hernias

usually

results

in

complete

recovery

within

a

period

of

up

to

6

weeks
.

Return to Work


Job Classification


RTW Min/Max



Sedentary Work



5 days


2 weeks



Light Work



5 days


2 weeks



Medium Work



2 weeks


4 weeks



Heavy Work



4 weeks


6 weeks



Very Heavy Work


4 weeks


8 weeks




One more thing!


Remember everyone copes with injury, illness and
pain differently. It is important to understand a
person’s mental status can directly affect their
recovery.