Health at work – Stroke – Strike while the iron is hot

Stroke may not be at the top of most practitioners’ lists of major workplace health concerns but, as Dr Chris Ide points out, its incidence is common and likely to become more so with changes in retirement-age legislation, so having robust return-to-work policies and procedures already in place will benefit sufferers.

According to the Neurological Alliance, there are about 10 million people in the UK with a neurological diagnosis. Obviously, severity varies widely, but about 40 per cent of the population who are severely disabled are crippled because of neurological disorders,1 including stroke.

Stroke is not often considered in occupational health and safety circles – probably because very few occupations carry an increased risk of stroke, and, more importantly, it is associated with the old, who do not tend to feature heavily in the workplace. Nonetheless, it is a significant contributor to the total burden of disability in the UK; a paper published in 2009 estimated the annual cost of stroke to the UK as being just short of £9 billion – just under 5 per cent of all NHS costs.2

Each year, about 100,000 people in the UK suffer their first stroke. As mentioned earlier, most are elderly, but about 25 per cent of stroke sufferers are under the age of 65, and so potentially eligible to be considered as workers. The costs can be attributed to 11 different categories:2 lost productivity represents just under 15 per cent of total expenditure; slightly less than 27 per cent is represented by informal caring, some of which will be provided by employees, who have to reduce their hours, or even leave their employment altogether to look after disabled relatives.

Furthermore, changes in the age of retirement will mean that the number of over-60/65s in the workplace will increase, so safety advisors may find themselves on the front line, when their employers turn to them for advice on the feasibility of returning stroke sufferers to the workplace.

A stroke is caused by disruption of the blood supply to the brain. There are two main types: ischaemic strokes, which occur when a blood vessel in the brain is blocked by a clot. Unless the clot is broken down very soon after it lodges in the cerebral circulation, then the brain tissue beyond it dies. Since nerve cells do not regenerate, their functions are permanently lost. The second main type of stroke is the haemorrhagic stroke. This happens when blood leaks out from a vein or artery and damages adjacent tissue.

In addition, there is a number of other, less common causes of intracranial bleeding (bleeding within the skull), which can present a similar picture, such as: sub-arachnoid haemorrhage, where the bleeding originates from an aneurysm (a balloon-like swelling) arising from a weakness at the junction of arteries at the base of the brain; arterio-venous malformations – abnormal connections between (high-pressure) arteries and (low-pressure) veins; clotting disorders; and not forgetting the bleeding that can occur from head injuries.

An understudied area

Although there is a colossal volume of medical literature on various aspects of stroke, very little of it deals with return to work. A review article3 cited 24 studies that purported to describe successful return to work, giving rates varying from 9-91 per cent, median 56 per cent. However, the authors wrote that, on closer inspection, the papers could not always be compared, since they used varying definitions of stroke, selected their study populations in different ways, and described follow-up times of varying duration. Some described very ‘soft’ endpoints, using resumption of household duties as a surrogate for resumption of work, for example, while others were criticised for inappropriate methods of statistical analysis.

Five years later, Treger et al4 performed a further review of 16 papers, 10 of which had formed part of the previously mentioned review. The return-to-work rate varied from 14-73 per cent, the median falling slightly to around 51 per cent. Their criticisms were similar but, in particular, they noted that, while there were many studies that documented failure (the italics are mine) to return to work, “[s]trikingly, the research does not tell us anything about effective intervention. The effectiveness of a rehabilitation programme must be evaluated by its ability. . .to improve the vocational outcome.”

While severity of the stroke (often measured in terms of length of hospital stay) obviously had a bearing on the likelihood of return to work, other important considerations included social factors, such as levels of unemployment, proximity of normal retirement age, family support and availability of social-security support. It was suggested that people interested in rehabilitating stroke victims of working age might care to draw on the experiences of those who had been involved with sufferers of traumatic brain injury, particularly since these individuals were usually of a younger age group.5

A further five years on, Tanaka et al6 attempted to remedy the failings of earlier researchers by reporting their findings of a group of 335 Japanese (80 per cent men), average age 55, who were working at the time of their first stroke. Thirty per cent returned to work within a month of discharge from hospital. Not surprisingly, these were characterised by being in ‘white-collar’ employment, and with mild disability.

Levels of mental function were also important independent predictors. Even with minor physical impairments, the presence of aphasia (reduction, or loss of ability to understand speech), apraxia (where the person is unable to carry out certain tasks, even though the command or request is understood) reduced the chance of this happening. Remaining in employment during the period of hospitalisation was also important, since those who lost their jobs during this time frequently found it difficult to get another one.

Stroke and the law

When bringing a person back into an organisation following apparent recovery from a serious health problem, the first thought should be: “Does this diagnosis have any statutory, or industry-mandated standard implications?” Obvious examples of this would apply to drivers (especially those who hold vocational licences), divers, seafarers, pilots, fire-fighters, police, and railway personnel, particularly those involved in track operations. (With regard to driving, it is important to remember that it is the licence-holder’s duty to inform the Driver and Vehicle Licensing Agency of any health impairment that is likely to last for at least three months and interfere with ability to drive.)7

Another legal instrument to be considered is the Disability Discrimination Act 1995, which, last year, was subsumed into the disability provisions of the Equality Act 2010.8 Discussion of these Acts often produces more heat than light, but the important thing is not so much whether the Act applies to a given individual in a specific set of circumstances (or not) but rather the nature of any adjustments required, and whether or not they are feasible for the organisation to implement.

It is generally held that health and safety legislation trumps equality law. While this is, in the main, correct, employers and those who work for them cannot merely hide behind: “You’re disabled, so there!” There have to be very precise reasons why a stroke victim cannot currently make the grade. In fact, there is often a great deal of overlap between the requirements of the Equality Act, and simple good personnel management. What is required is “a proportionate way of achieving a legitimate aim”.

This may seem a big ‘ask’ but remember that the alternatives to trying to rehabilitate an individual may well be to reallocate duties, which may be unpopular among those to whom the extra duties are devolved, especially if this is for an indefinite period. Another possibility might be to recruit a replacement, but this will take time, and the chosen person will inevitably also take time to settle into their new slot.

Support sources

If the organisation has its own occupational medical advice, then it will be likely that the doctor or nurse running the service will already have heard about the incident via sickness-absence reporting policies and will have taken steps to enquire about the extent of the recovery from the employee’s medical attendants. If no such assistance is immediately available, it may be helpful to enlist a suitably qualified source of advice.

Rather than just Googling ‘occupational health in wherever’ and clicking on the first link that appears, it is advisable to have a quiet word with local colleagues, who may be able to recommend helpful (or not!) services and then further checking these services against external quality validators, such as ISO 9001:20089 and/or the Faculty of Occupational Medicine’s own SEQOHS (Safe, Effective Quality Occupational Health Services) benchmarking scheme.10

Possession of either or both of these imprimaturs indicates that the organisation concerned has appropriately qualified staff, who keep themselves up to date  and undertake regular audit of activities, with the aim of constantly improving the services offered to customers.

Should your organisation still wish to depend on its own efforts, at some point it may well be necessary to contact the employee’s medical advisors, whether in general or specialist practice. Whoever is approached will only respond to your queries if they have evidence of written agreement from their patient, and that (s)he has had their rights under the Access to Medical Reports Act, etc. explained to them.

It is probably more appropriate to approach the general practitioner, at least in the first instance, because the GP, in their role as coordinator of the employee’s care, will receive reports from all agencies involved in the case. The GP is also likely to be more aware of other non stroke-related health problems that may have a bearing on return to work, and may advise on these, if appropriate questions are put.

The doctor who receives your letter will find it easier to respond if some indication of what the job involves is included, i.e. a good, non-technical job description. Questions should be put regarding the diagnosis, which is particularly relevant from the point of view of standards referred to earlier.

More important for those supervising the return to work – particularly if no OH guidance is available – is to put the questions in such a way that they can be answered in terms of that person’s ability to function at their job, e.g. to move around, handle tools, effects on visual fields, etc. It would be helpful for the employer to know what plans existed for further medical management/ rehabilitation, in order to facilitate time off to attend any further appointments.

Finally, some indication of longer-term outlook will be helpful, although, generally speaking, it will only be apparent four to six months post-stroke which functions are recovering most effectively, and which are not. Assuming adequate rehabilitation facilities are available, and deployed at appropriate times, by 12-15 months, the recovery will likely be as good as it is going to get.

One particular problem is post-stroke fatigue. To some extent, this is due simply to the deconditioning that occurs following any prolonged sickness absence. This will be alleviated by settling into the routine following return to work. More troublesome, however, is the manifestation of fatigue as a cognitive defect arising from subtle brain damage caused by the stroke.

This, and other problems, such as changes in risk-taking behaviour and personality changes may only become apparent as the return to work progresses. To some extent, this may be amenable to further specialist help, but a modification of duties, and/or reduction in hours may have to be considered at some point.

Physiotherapists and occupational therapists can offer useful advice on modifications to the workplace environment, or equipment and tools. Funding assistance may be available through the ‘Access to Work’ programme administered by the disability employment advisors at Jobcentres, although application for assistance through these schemes must come from the affected individual. A charity like ‘Abilitynet’ can provide advice on IT problems, if the organisation’s own specialists are unable to help.

A further relevant factor will be the extent to which it has been possible to reduce the likelihood of a subsequent stroke or bleed. While there is a number of prediction devices available, many of them are unsuitable because they apply only to asymptomatic people, i.e. those who have not had a heart attack, or a stroke, and/or they classify people into very broad groups.11

Apart from age and gender, about which nothing can be done, there are factors like significantly raised blood pressure, lipid disorders, such as high levels of cholesterol or other blood fats, a persistently irregular heart beat, sources of blood clots and diabetes – all of which increase the risk of stroke occurring in the first place, let alone that of recurrence. These are potentially amenable to being brought under control, thus improving the outlook for the future.

Nonetheless, optimum control of various risk factors may only be obtained via the use of polypharmacy (multiple drug prescriptions), the side effects of, or interaction between, which can affect performance. However, these may reduce over time as the body brings drug metabolising enzymes into play, speeding up breakdown or, as a result of good doctor-patient liaison, more intelligent spacing of doses, substituting medicines that have less troublesome side effects, or discarding the least valuable drugs.

Practitioner input

Safety advisors can use traditional skills in making the workplace safer – by reducing the chances of significant head injury, for example. If they have oversight of the first-aiders, they should ensure that they are up to date with appropriate first-aid recognition and treatment for stroke – particularly the FAST acronym (Face – does the mouth/eyelids droop at one side?; Arms – can they both be raised to the same extent?; Speech – is it slurred? T – Time to call 999).

In fact, this should really be publicised throughout the workplace (see poster above), and the first-aiders should be competent in administration of oxygen to maximise the amount of that life-sustaining gas that reaches the brain. Sometimes, the symptoms mentioned above will settle within 24 hours – a transient ischaemic attack (TIA), or mini-stroke. While this should be grounds for relief if it happens, it is essential that the employee consult their GP at an early opportunity to allow further investigations to take place, since, if nothing is done, there is a one in 10 chance of a completed stroke occurring within four weeks.12

Conclusion

At the beginning of this article, I wrote that “…there are very few occupations which carry an increased risk of stroke”. What I meant was that there are few occupations associated with stroke in the same way that (say) asthma is associated with bakery employees. Studies, particularly of Japanese workers, have tended to show that what is much more important is not so much the job itself but the amount of control the employee can exert over the task. This is particularly relevant to blue-collar male workers; a recent study over an 11-year period showed that the stroke risk increased almost three times in those who had the least control over the demands of their work.13

As front-line ‘activists’, safety advisors can help bring seriously ill people back into a more productive lifestyle, which may well also benefit the organisations that employ them both. 

References
1 www.neural.org.uk/store/assets/files/19/
original/Neurological-Alliance-Briefing-on-Welfare-Reform.pdf 
2 Saka O,  McGuire A, Wolfe C (2009): ‘Costs of stroke in the United Kingdom’, in Age and Ageing 2009;38:27-32
3 Wozniack MA, Kittner SJ (2002): ‘Return to work after Ischaemic Stroke: A Methodological Review’ in Neuroepidemiology 2002;21:159-166
5 Ide, CW (1995): ‘Mind your head’, in Safety & Health Practitioner, 1995,13;12:16-18
6 Tanaka H, Toyonaga T, Hashimoto H (2011): ‘Functional and Occupational Characteristics Associated With Very Early Return To Work After Stroke in Japan’, in Arch Med Phys Rehabil 2011, 52;743-48
4 Treger I, Shames J, Giaquito S, Ring H (2007): ‘Return to work in stroke patients’, in Disability and Rehabilitation 2007,29;17:1397-1403
7 www.dft.gov.uk/dvla/medical/ataglance.aspx
8 www.direct.gov.uk/en/DisabledPeople/
RightsAndObligations/DisabilityRights/DG_4001068
9 www.british-assessment.co.uk/iso-9001-certification-services.htm
10 www.facoccmed.ac.uk/library/docs/
standardsjan2010.pdf
11 www.bhsoc.org/Cardiovascular_Risk_
Charts_and_Calculators.stm
12 www.nhs.uk/conditions/Transient-ischaemic-attack/Pages/Introduction.aspx
13 Tsutsumi A, Kayaba K, Ishikawa S (2011): ‘Impact of occupational stress across occupational classes and genders’, in Soc Sci Med 2011,72;10:1652-58

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In this episode  of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.

We provide an insight on how to tackle burnout and why mental health is such a taboo subject, particularly in the workplace.

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