Guest blog by Dr. Finola Ryan and Dr. Lucia Batty
Workers with health conditions considered to make them extremely vulnerable to COVID-19 were advised by the government to observe ‘shielding’ for 12 weeks. Pre-habilitation, or ‘prehab’, is the optimisation of an individual's functional capacity to enable him or her to withstand a forthcoming stressor, commonly used prior to undergoing surgery. The process involves addressing medical issues, physical exercise, fitness, nutrition and enhancing psychosocial/emotional wellbeing with reduction or acceptance of sources of stress or anxiety.
The return to work at the end of the shielding period is a foreseeable matter where a deconditioned worker may be fearing return to work, and occupational health (OH) have an opportunity to address the above mentioned (physical, psychological and emotional) issues affecting the shielded worker. OH can positively impact and empower individuals to resume working, however there are wider organisational and national concerns like assurance of robust measures including ongoing adequate protection via PPE, staff and patient testing and observing restrictions such as social distancing.
A robust plan could influence workers’ health behaviour, productivity and continued participation and engagement in the workplace. An active approach in the weeks leading up to returning to work could give the worker autonomy and rebuild their confidence with multidisciplinary support.
Cardiorespiratory and musculoskeletal deconditioning
Physical activity and good cardiorespiratory fitness levels have a synergistic effect on the body’s ability to deal with impending stresses. This is not exclusive to physical health. An enormous amount of research has shown the positive impact of exercise on psychological wellbeing. A worker who has observed shielding will doubtlessly have an enforced period of relative inactivity, having been advised against leaving their house. Physiological adaptations to muscular inactivity manifest as increased insulin resistance causing high blood pressure, blood glucose and blood lipids alongside decreased stroke volume, increased heart rate and decreased ventilatory efficiency resulting in decreased VO2max and decreased exercise capacity.
A phased return to non-exercise daily activities such as climbing the stairs rather than using a lift and taking 5-minute activity breaks during sedentary activities will be as important as graded return to exercise toward the end of the shielding period. When restrictions are lifted, walking to the shops rather than using a car will present an opportunity to engage with society as well as allow graded return to exercise. Workers who require musculoskeletal strength and dexterity are likely to experience loss of muscle strength and deconditioning during shielding. This unloading also affects bone and turn-over at weight-bearing skeletal sites and collagen turn-over in tendons and muscles. Proprioceptive mechanism become less responsive, placing the worker at increased risk of injury. Occupational health is in a good position to engage with workers and managers to ensure a safe successful return to work following shielding.
Complex health anxieties
Whilst the UK Government announcement of a ‘lockdown’ offered some assistance to the NHS to ‘flatten the curve’, apart from the significant financial consequences, very real challenges arose around the profound impact of self-isolation and social distancing on mental health. People had to adopt new routines living away from their families, friends, places of worship, working from home and have had to learn to process an overload of potential fear-setting and confusing information coming from social media.
A prolonged period away from the workplace can be a source of anxiety, now heightened in the presence of a pandemic. In addition, the stark reality that the worker is considered extremely vulnerable should they become infected, and the workplace may now be viewed as an unsafe environment from their perspective. While further discussion of these issues is beyond the scope of this article, it is worth noting the positive impact of physical activity on many common mental health conditions and the ‘prehab’ approach could be a route to addressing stress and anxiety. A single episode of exercise confers immediate results on lowering blood pressure, improving sleep, reducing anxiety, improving insulin sensitivity and mental function.
Getting workers back to work – keeping them back at work
Prehab doesn’t end on return to work. Ongoing review with bespoke risk assessment and advice on allocation of tasks and activities are necessary to prevent injury, address stressors and worries and prevent foreseeable sickness absence.
At King’s College Hospital NHS Foundation Trust, we are developing a didactic guidance on exercise and mental health rehabilitation for shielded workers in weeks before their anticipated return to work, based on their pre-COVID morbidities and daily activities. We will be sharing this widely with colleagues in the wider occupational medicine community.
Dr. Finola Ryan is a Specialist Registrar in Occupational Medicine. Dr. Lucia Batty is a Consultant Occupational Physician.