OH Today Winter 2021

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Partners of OH Today

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OH TODAY

Winter 2021

CONTENTS

Editor

From the President

5

The Impact of Climate Change on Global Health

8

A Spotlight on Muscular Skeletal Conditions

14

The Value of Physiotherapy Input into Long Covid Support

18

Combatting fatigue!

26

Health and Wellbeing@Work 2022

30

What are the respiratory implications of COVID-19?

32

Promoting healthy nutrition: an opportunity for occupational health specialists

38

Interview with Charlie Wakeley

41

LYNN PRATT Assistant Editor JANET O’NEILL Production Editor IAN GARNER

Copyright © iOH 2021

Published by iOH, The Association of Occupational Health and Wellbeing Professionals

ioh.org.uk

email: admin@ioh.org.uk

Views expressed in OH Today are those of the contributors and not necessarily those of iOH.

Nor does iOH necessarily endorse any of the products or services mentioned or advertised in the publication. ioh.org.uk

OH TODAY

3

From the President Neil Loach

W

elcome to the Winter Edition of OH Today. We are sure that you will enjoy

the wealth of articles that are on offer this month.

For this edition I wanted to focus on what we have done in the Last year along with what our future aspirations are for the year ahead.

It has now been a year since I became

Guidelines in Health Surveillance

• IT Accessibility • Supporting WFH employees living with Pain • Sight Loss • Prostate Cancer • Menopause • Transgender Issues

President and it still continues to be an

• Critical Reflection

honour to serve within the role. The

• Process Mapping Covid-19 RTW

Team at iOH have been extremely busy managing their day to day working and personal lives but have still managed to give 110% to iOH. I offer my sincere thanks to all of them.

We have held 21 webinars for the series 21 for 2021 and all have had good

• Along with 4 sessions of BSL and other unrecordable sessions due to privacy and confidentiality.

The whole series has been phenomenally successful with over 1000 bookings and 500 attendances.

attendance and a few with exceptional

OH Today goes from strength to

attendance. We hope that you have

strength and regularly receives over

enjoyed them as much as we have.

3000 engagements across the many

Recordings have been made for many of

platforms we offer it to. The quality of

the webinars and can be found on our

writing continues to excel and the

YouTube Channel here. Topics included:

editorial team has been busy to ensure

• Diversity

that the quality keeps on getting better and better. A huge appreciation for their

• Silicosis

work goes to Lynn Pratt and Janet

• Mental Health & Suicide Prevention

O’Neill for their sterling work.

• Restarting Spirometry

The website continues to get better and

• Ehlers Danlos Syndrome

more work will take place in the coming

months to ensure it remains as good as

• Critical Writing at Masters Level

it can be for our members.

• Implementing ATS /ERS Spirometry

We currently have 662 members and this

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Overall, the focus of the last year has been about supporting our members with their CPD during a time when many of the face-toface sessions for this have been cancelled or postponed.

is up by over 1200% from March 2020. A

and fit for the future of OH. Our work

phenomenal effort by the Team and this

with the Council for Work & Health

is all due to engagement with our

continues and we are ably supported by

members and superb value for money in

our NED Angela Whitehouse in this

terms of what we deliver for the benefit

regard. We have also been working

of the OH Community. To my

closely with the Health & Safety

knowledge it is the biggest membership

Executive on projects with Lynn Pratt &

we have had in our history.

Libby Morley being responsible for this

Our impact within the regional groups

input on behalf of our members.

has not been fruitful and it is with this

Overall, the focus of the last year has

in mind we have decided to withdraw

been about supporting our members

this offer of engagement and leave it in

with their CPD during a time when

the capable hands of the independent

many of the face-to-face sessions for

regional groups. We will of course give

this have been cancelled or postponed.

updates and support to regional groups

We will continue this focus for the

whenever requested.

coming term.

We have been busy assisting the NMC

Finally, as you know we are supported

with the new SCPHN Standards and this

by Vitalograph UK and this partnership

work will continue for the foreseeable

has gone from strength to strength and

future until the new standard needs to

has been beneficial to both

be implemented. We will ensure that we

organisations. We are proud to

are at the table for any decisions that

announce that this has been secured for

are made to ensure they are attainable

a further year.

The Year Ahead

W

e are proud to announce that The NEC H&WB@W Conference will see a

subsidised Gala Dinner open to 60 members on the night of 15th March 2022 and the Ruth Alston Memorial Lecture will be delivered by: Professor Dame Carol Black. The title of her Lecture will be:

Independent Review of Drugs: What part should Occupational Health Professionals play?

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Winter 2021

Dame Carol was commissioned by the

will be open before Christmas if we are

Home Office and the Department of

able to. (The dinner is a 3 course formal

Health and Social Care to undertake a 2-

dinner, pre-dinner drinks and a glass of

part independent review of drugs, to

wine with the meal. It will be held at the

inform the government’s thinking on

Hilton Metropole Hotel which is only a

what more can be done to tackle the

short walk to the NEC.

harm that drugs cause.

My focus for the future as President is to

Part one was published on 27 February

deliver a session within the Leadership

2020 and provides a detailed analysis of

& Management sessions at the

the challenges posed by drug supply and

HWB@W Conference on “Clinical

demand, including the ways in which

Supervision in OH – What are the

drugs fuel serious violence. Part 2 was

benefits?”. We will also investigate the

published on 8 July 2021 and focuses on

possibility of providing training to 15

drug treatment, recovery and

Clinical Supervisors who will each be

prevention.

asked to take on 2-3 Supervisees. We

The report’s aim is to make sure that vulnerable people with substance misuse problems get the support they

will be doing an evaluation and disseminating the results back into practice before considering expansion.

need to recover and turn their lives

We are currently in discussion with

around, in the community and in prison.

Vitalograph UK to secure more webinars

It contains 32 recommendations for

and the potential for several free

change across various government

spirometry updates (members only).

departments and other organisations, to

Details will be announced once this has

improve the effectiveness of drug

been finalised. I know OH Today will

prevention and treatment and to help

continue to flourish and the website will

more people recover from dependence.

continue to be improved. We will also be

(GOV.UK, 2021) The event is sponsored by Vitalograph UK. The evening will be an immensely enjoyable event if previous years have anything to go by and I am pleased to be inviting 60 members to book for the event at a subsidised price of approximately £42. Non-Member price will be £55. This represents phenomenal value to our members with you receiving 1.4 years of membership monies back in subsidy for the event. If you are not a member currently you should join by

consulting with members on what they want for the future in terms of services and support.

Please welcome our New Directors, Charlotte Wakeley (Student Affairs) and Tim Ellis (Media and Communications).

I’m certain they will be an asset to Team iOH! Finally, I would like to take this opportunity to thank you for all the support you have given Team iOH over the last year. Please Have a Merry Christmas and a Very Happy New Year 2022. Stay Safe!

31st December to get the discount. Our

Neil Loach

records will be checked to ensure

President, iOH

fairness. It will be a first come first served basis for booking and booking ioh.org.uk

OH TODAY

7

The Impact of Climate Change on Global Health

By Stephanie Foster, Clinical Training Lead, PAM Group

T

he recent UN Climate Change

prediction that the temperature will

built environments both

Conference (COP26) in Glasgow

continue to escalate without

retain heat, they are on

has drawn a spotlight on the

intervention. The prediction is that we

degrees hotter than the

impact of human activity on the climate.

will continue to experience an increase

countryside 2. As heat ris

Within the scientific community, it is

in the frequency and severity of adverse

high-rise flats or offices

readily accepted that our reliance on

weather conditions This includes

with large unshaded win

fossil fuels, the loss of natural habitats

heatwaves, colder winters, drought,

experience problems wi

and large-scale farming is causing a

increased episodes of heavy rainfall,

In the UK more focus ha

substantial rise in greenhouse gasses

storms, and high winds. So, from an OH

reducing heat loss from

resulting in a rise in global temperature.

perspective how might this impact our

rather than considering

health and work here in the UK?

insulation can help redu

The start of the industrial revolution

1

2.

150 years ago has been used as a

Heatwaves, where temperatures exceed

benchmark, with the planet’s

25 to 28oC for at least 3 consecutive days

temperature having risen by one degree

often accompanied by high humidity,

Celsius since then, with the stark

will become more frequent. As cities and

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Winter 2021

of heat entering the buil

heat loss in cooler times

reduce the dissipation o

conjunction with the ret

released back into the environment, can

more vulnerable to the impact of heat

result in elevated temperatures at night.

and to developing a heat-related

This can adversely affect sleep patterns

illness.5 The HSE have a dedicated

causing fatigue and associated issues

microsite to temperature, which has

such as reduced productivity and an

detailed advice on eliminating, reducing

increased level of accidents. Opening a

or mitigating the associated risk through

window is often the initial method used

a hierarchical approach to implementing

to reduce the ambient temperature. This

appropriate control measures.6

is a measure that is encouraged to help reduce the spread of COVID by improving ventilation. However, a

cooling effect can only occur if the outside air temperature is lower than

The NHS website describes symptoms of heat exhaustion as:

that inside. When it is not, it can have the opposite effect, increasing indoor temperatures.

Employers may need to reconsider how they achieve both good ventilation and maintain an acceptable working temperature in this scenario.

• a headache • dizziness and confusion • loss of appetite and feeling sick • excessive sweating and pale, clammy skin

Mechanical alternatives such as a fan or

• cramps in the arms, legs and stomach

air conditioning, can both help and

• fast breathing or pulse

hinder. Some industries have the added complication of having heat dependent processes, exacerbating the situation

• a high temperature of 38C or above • being very thirsty

even further e.g., kitchens, laundries, or foundries.

Although there is no current maximum

https://www.nhs.uk/conditions/heatexhaustion-heatstroke/

working temperature set in legislation,

h produce and

average 5 surrounding

ses, south-facing

s, especially those

ndows can

th overheating.

as been given to our buildings cooling. While

uce the amount

lding, as well as

s, it can also

of heat. This in

tained heat

Workplace, Health, Safety and Welfare Regulations state that employers must maintain “a reasonable temperature.”3, productivity within office workers has been shown to decrease above 23-240C.4 As we experience more sunshine, outdoor workers may experience increased UV exposure and therefore be at an ever-increasing risk of developing skin cancer. They also do not necessarily have the protection of shade or easy access to fluids, while also being more

likely to be carrying out physical activity. Consequently, they, like pregnant women and those with a disability or underlying health issues are

Increased temperatures can also exacerbate existing health conditions.

For example, most people with Multiple Sclerosis (MS) report experiencing increased issues with fatigue, blurred vision, balance, and cognitive issues when feeling over-warm or hot.7 Hot weather can also impact blood glucose control for people with diabetes, increasing the risk of hypoglycaemia due to a combination of better insulin absorption and dehydration. Sweating to regulate temperature and heat-related fatigue can also make it harder to

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recognise hypoglycaemic warning

reduction in air quality, as strong

signs.

sunshine increases ozone and pollution

8

Higher temperatures can also impact on cardiovascular, renal, and respiratory conditions. In very hot weather the heart must work harder to maintain the body’s core temperature within optimal levels. Those with pre-existing cardiovascular conditions are less able to accommodate the vasodilation required to achieve this.9 The consequence is reduced blood flow and oxygenation of the major organs, potentially resulting in failure.

Heat stress can affect kidney function and is thought to be a contributing factor in the development of chronic kidney disease. Heat stress and dehydration are also considered to be contributing factors in the formation of kidney stones. While not drinking sufficient fluids can increase the risk of urinary tract infections10. Heatwaves are associated with an increased mortality rate. If nothing changes it is expected by 2050, we will experience a 250% increase in heat-related deaths to around 7,000 a year, predominantly affecting the elderly.11 There is also some evidence of an increased mortality rate amongst those taking medications to treat mental health issues, possibly due to side effects such as the suppression of thirst and altered levels of perspiration.12 Going forward, it may be that we need to consider the risk caused by heat exposure for a wider range of employees and work settings, not just those who are exposed to a heat-generating process.

When considering the impact on respiratory function, higher temperatures are associated with a

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Winter 2021

levels. It is believed that warming will increase levels of pollen and fungal spores and that these may also trigger allergic reactions more readily. The hay fever season is predicted to become longer and to increase the frequency and severity of asthma attacks.13 Current advice is for hay fever sufferers to keep windows closed. It will be

interesting to see how this competing demand to keep windows open to aid ventilation as a COVID secure measure can be managed. This may be another area where home working, where it can be accommodated, allows for personalised environment management to meet an individual’s health needs.

As the climate warms there is an increased risk of drought and

consequently wildfires, the impact of the particulates produced has an impact on lung function, exacerbating chronic respiratory disease. There is also evidence of the increased frequency of strokes and heart attacks in the vicinity of these fires.14 While those who are fighting the fires will be provided with appropriate PPE and indoor workers advised to close windows and stay

inside, outdoor workers in the area may be exposed to higher levels of particulates. If the air quality is sufficiently affected, employers may need to consider PPE to mitigate the risk.

Periods of drought and conversely increased risk of flooding from high levels of rainfall impact agriculture and yields.1 Poor harvests result in higher

prices increasing the food insecurity already prevalent. We already have extensive evidence that this is a contributing factor in the development

Occupatio specialists unique posi able to consid impacts of c working po how an in employment their exp person

onal Health s are in the ition of being der the health climate on the opulation and ndividual’s t might affect posure and nal risk.

of health inequalities. Higher

In this country, we are more used to

temperatures may also increase the

considering the impact of cold rather

prevalence of vector-borne diseases. For

than hot weather. The very recent

instance, increasing temperatures have

storm Arwen has highlighted the

increased the prevalence of ticks and

adverse impact of both the cold and high

mosquitoes. However, if the climate

winds, with 3 people, unfortunately,

continues to warm, we may also

losing their lives when their vehicles

experience an influx of more exotic

were hit by falling trees. Parts of

species and associated pathogens. There

Scotland have been without electricity

may be COSHH (Control of Substances

for over 7 days as power lines have been

Hazardous to Health) implications as

brought down by the weight of snow and

new chemical controls may have to be

ice. It is not just the amount of

developed to manage this.

infrastructure damage that is causing delays to reconnection, but

Due to melting glaciers and ice flows,

environmental conditions. Working in

sea levels are anticipated to rise. This

cold conditions, like extreme heat can

may put coastal regions at risk of

impact health, limiting how long

flooding. I was surprised to find that Cardiff is considered the 6th most at-risk city in the world of flooding, while

workers can be operational as regular rest breaks to warm-up are required.

Vasoconstriction to help maintain core

London is 22nd.15 Increased periods of heavy rainfall are also having an impact

with some areas becoming prone to

body temperature can impact the

cardiovascular system increasing the risk of heart attacks and strokes. It can

repeated flooding. While we are all

also increase the risk of cold injury to

aware of the economic impact of this,

the extremities and impact manual

we may not have considered the

dexterity.

psychological impact. Research has shown this does not just occur at the

A study by the TUC has highlighted that

time of the flood but that there is an

most employers have experienced

increased prevalence of Post-Traumatic

increased absenteeism associated with

Stress Disorder and depression in those

adverse weather events, be that due to

affected by flooding up to 3 years later.

health, travel or infrastructure issues.

16

There is often limited statutory support

While 70% acknowledge the health and

to deal with the clean-up and

safety implications and risks to their

restoration following such events, which

workforce from future climate change.17

can take many years. Due to increased moisture, this can lead to an increase in mould growth increasing respiratory problems. Businesses, as well as homes, can be flooded affecting the economic and mental health of communities due to long layoffs. In 2005 The McVities

factory in Carlisle was flooded causing a 6-month national shortage of bourbon biscuits until the factory could be made operational again.

Occupational Health specialists are in the unique position of being able to consider the health impacts of climate on the working population and how an individual’s employment might affect their exposure and personal risk. We can have a key role in helping to interpret

the science, raise awareness and support individuals and businesses in their attempts to mitigate the health impacts of climate change. I hope that this ioh.org.uk

OH TODAY

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article may have helped to spark

temperaturesensitivity#heat-

discussion and reflection on how climate

sensitivity. [Accessed 5 December

change is already impacting our health

2021].

and may still do in the future.

References

weather. [online] Available at:

1. Nations, U., 2021. Climate Change | United Nations. [online] United Nations. Available at: https:// www.un.org/en/global-issues/ climate-change [Accessed 21

November 2021].

2. UN Climate Change Conference (COP26) at the SEC – Glasgow 2021. 2021. UN Climate Change Conference (COP26) at the SEC – Glasgow 2021. [online] Available at: https://ukcop26.org/ [Accessed 29 November 2021].

3. The Workplace (Health, Safety and Welfare) Regulations 1992.

4. Seppanen, O., Fisk, W.J. and Lei, Q.H., 2006. Effect of temperature on task performance in office environment. [online] Available at: Effect of temperature on task performance in office environment (escholarship.org) [Accessed 29 November 2021].

5. WHO, 2021, Heat and Health. World

Health Organisation Available at: https://www.who.int/news-room/ fact-sheets/detail/climate-change -heat-and-health. [Accessed 4 December 2021] 6. HSE, 2021, Temperature. [online]

https://www.diabetes.co.uk/ diabetes-and-hot-weather.html [Accessed 5 December 2021].

9. CDC, 2021. Heat: Cardiovascular Health. [online] Available at:

https://www.cdc.gov/ climateandhealth/docs/ HeatCardiovasculoarHealth508.pdf. [Accessed 5 December 2021].

10. Johnson, R., et al, 2019. Climate Change and the Kidney. Annals of Nutrition and Metabolism, 74 (Suppl. 3), pp.38-44. [online] Available at Climate Change and

the Kidney - PubMed (nih.gov) [Accessed 5 December 2021] 11. Ellicott. A., 2021. Rollins School of Public Health. [online] Available at: http://www.sph.emory.edu/ [Accessed 5 December 2021].

12. Stöllberger, C., Lutz, W. and Finsterer, J., 2009. Heat-related side-effects of neurological and non-neurological medication may increase heatwave fatalities. European Journal of Neurology, 16(7), pp.879-882. [online] Available at: https:// onlinelibrary.wiley.com/doi/ abs/10.1111/j.1468-

Available at: Available at: https://

1331.2009.02581.x [Accessed 5

www.hse.gov.uk/temperature/

December 2021].

index.htm. [Accessed 5 December 2021].

13. Vardoulakis, S. and Heaviside, C., 2012. Health effects of climate

7. MS Trust. 2021. Temperature

12

8. Diabetes. 2021. Diabetes and hot

change in the UK 2012. London:

sensitivity. [online] Available at:

Health Protection Agency.

https://mstrust.org.uk/a-z/

[online] Available at: Climate

OH TODAY

Winter 2021

change: health effects in the UK -

change-city-index/ [Accessed 6

GOV.UK (www.gov.uk) [Accessed

December 2021].

online 21/11/2021] 14. Anchor. 2021. OccPod: Climate

16. GOV.UK. 2021. Mental health costs of flooding and erosion. [online]

Conversations – Episode 21,

Available at: https://www.gov.uk/

Wildfires and Environmental

government/publications/mental-

Hazards by OccPod: the official

health-costs-of-flooding-and-

ACOEM podcast. [online]

erosion [Accessed 6 December

Available at: https://anchor.fm/

2021].

acoem/episodes/OccPod-ClimateConversations--Episode-21-Wildfires-and-EnvironmentalHazards-e1a3qit [Accessed 6 December 2021].

15. Nestpick.com. 2021. 2050 Climate

17. Tuc.org.uk. 2021.Changing Work in a

Changing Climate [online] Available at: https:// www.tuc.org.uk/sites/default/ files/extras/adaptation.pdf [Accessed 6 December 2021].

Change City Index | Nestpick. [online] Available at: https:// www.nestpick.com/2050-climate-

ioh.org.uk

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A Spotlight on Muscular Skeletal Conditi

By Tom Middleton, Advanced Practice MSK Physiotherapist, Connect Health

M

y last physio patient has just

musculoskeletal (MSK) pain or be part of

left the clinic and their knee

a much more complex condition

arthritis flare up has settled

affecting multiple bodily systems. The

down well with some advice and

Beighton score is a quick and easy tool

exercises. Next in I have a referral for

commonly used to diagnose generalised

Laura (not her real name), a 26-year-old

joint hypermobility in children and

retail assistant who is off sick. She has a

adults. It gives a score out of 9,

history of long-standing anterior knee

whereby positive is > 5 for

pain and previous patella dislocations. I

adults up to age 50.

note her medical history also states previous physio attendances for back pain, wrist and hand pain, neck pain and ankle sprains. She has chronic fatigue, multiple allergies, genitourinary issues, anxiety and problems with palpitations

and dizziness. She’s had an inflammatory condition excluded and it doesn’t really fit that picture. Her GP is querying fibromyalgia. I’m surprised by her having problems with multiple bodily systems at such a young age and wonder if they could be linked? I’m a little daunted by her complexity and just know my 20-minute appointment will not be enough!

somebody with a kind of joint hypermobility with one or more

associated MSK problem. It may present just in the peripheral joints, localised to one joint or a group, historical (once hypermobile but no longer) or generalised / widespread hypermobility.

Hypermobility Spectrum Disorders (HSDs) can be visualised on a continuum from asymptomatic joint

hypermobility at one

Simply put this is excessive joint

Ehlers Danlos

can vary from a single joint to a pair / group, to a more generalised

end to Hypermobile Syndrome (hEDS) at the other.

Olympic swimmer Michael Phelps). This

The Ehlers Danlos Syndromes

is termed asymptomatic joint

These are a group of 13 conditions

hypermobility affecting the spine and multiple joints. For some people this may never lead to pain and in fact be advantageous (You’ve probably heard of

hypermobility. However, for some hypermobility can contribute to

OH TODAY

This is the recognised term for

What is hypermobility? movement. Think “double jointed”. This

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Hypermobility Spectrum Disorder

Winter 2021

mainly characterised by joint hypermobility, skin hyperextensibility

Overall, they range from rare to

Associated Musculoskeletal Problems

extremely rare. Twelve have an

Joint hypermobility can affect people in

ions

and tissue fragility. They are inherited

,

involve the connective tissue collagen.

and their genetic causes generally

identified genetic marker but the most common – hypermobile Ehlers Danlos Syndrome – is yet to be identified. For now, there is a helpful diagnostic criteria checklist. However,

someone with HSD may well have signs and symptoms equally as debilitating as hEDS but not quite meet the specific hEDS diagnostic

criteria.

This article will focus on HSD and hEDS as these are by far the most common. Vascular EDS is rarer and should also be suspected in anyone with peripheral joint hypermobility, thin translucent skin and a tendency to bruise catastrophically. Its gene

defect affects type 3 collagen which is found in large hollow organs.

Spontaneous pneumothorax, arterial, sigmoid colon, or uterus rupture can occur which can have fatal consequences. Early identification is key to managing this condition as it is often sadly diagnosed following a catastrophic event. Both hEDS and vEDS have an autosomal dominant inheritance

pattern. If one parent had the condition each child had a 50:50 change of inheritance.

a range of ways. Common is persistent musculoskeletal pain and it is believed this may be due multiple factors including excessive joint movement causing repetitive microtrauma to soft tissues. More obvious trauma may also

be evident such as joint subluxations and frank dislocations. Reduced proprioception (your joint position sense) and muscle weakness is common.

A recent systematic review suggested exercises to address these deficits usually yield good results.

Commonly associated with HSD and hEDS are conditions extending past the musculoskeletal system. Someone may have none, some or all of these associated conditions. Often these can be more debilitating than the MSK symptoms themselves.

Cardiac Dysautonomia The autonomic nervous system regulates the bodies automatic processes such as heart rate, blood pressure and digestion. Dysfunction of

these is commonly seen in HSD and hEDS. The main cardiac presentations are orthostatic hypotension (rapid drop in BP when standing) and postural orthostatic tachycardia syndrome (POTS). POTS is usually characterised by a sustained increase in BP of 30 bpm soon after standing without significant drop in BP. Symptoms often include fatigue, light headedness, dizziness, and

palpitations when standing and intolerance to exercise. There are various suggested underlying causes for these and their link to hypermobility.

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Understandably POTS can cause

growing recognition of links to

somebody significant anxiety as well as

neurodevelopmental disorders. A

functional impairment so adequate

Swedish study found EDS had an

support and management is key. First

increased relative risk of 5.6 for

line management recommendations

attention deficit hyperactivity disorder

include increased salt and fluid intake,

and 7.4 for autistic spectrum disorder.

carefully building exercise tolerance,

The cause for these associations is

compression garments and avoiding

unknown.

triggers for vasodilation such as hot environments, sudden changes in

Mast Cell Disorders

posture and large carbohydrate meals

Mast cells are involved with the body’s

(insulin is a vasodilator).

immune system response. They are

Genitourinary and gastrointestinal disorders Genitourinary (GU) and gastrointestinal (GI) disorders are also associated with HSD and EDS. The GU system and pelvis contain many collagen rich tissues and a broad range of issues have been reported. GU problems can include incontinence, pelvic organ prolapse and pain. Incidences of menstrual disorders, pregnancy complications and pelvic girdle pain are also increased.

found throughout the bodies tissues and when they become “activated” by a stimulus they help initiate an inflammatory response. They are best known for their role in allergic reactions. When someone has increased activation of mast cells it is known as mast cell activation disorder (MCAS) and this is common in HSD and hEDS.

Symptoms can vary hugely in severity from mild reactions to anaphylaxis. Common symptoms are itching, swelling, redness, abdominal pain and diarrhoea. Triggers widely vary but can commonly include alcohol,

GI disorders commonly include

foods, medications, heat (environmental

abdominal pain and bloating. Bowel

or increased body temperature),

transit problems from constipation to

infection, surgery, insect stings,

IBS are also common and may relate to

chemicals, and stress. It is

dysautonomia. Structural problems may

recommended people with MCAS work

include hernias and rectal prolapse.

closely with a treating doctor to firstly

For GU or GI problems early referral to a specialist is key to managing symptoms and reducing associated anxiety and impact on daily life.

Mental health associations A strong association has been observed

between HSD/hEDS and psychiatric disorders such as anxiety, depression and eating disorders. Also, there is

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OH TODAY

Winter 2021

identify and avoid triggers. Allergies to various medications may then mean various low dose medications are trialled one at a time and gradually increased. MCAS is presently incurable.

Fatigue Fatigue is the most disabling symptom according to EDS patients and responds less well to treatment than other outcomes such as pain. A survey found

It is vital th health prof and emplo involved in communic with each o creating a centred ne

hat we, the fessionals, oyers n care cate well other, patient etwork

its prevalence in EDS of over 75%.

may have multiple diagnoses and be

Medical assessment and relevant

seeing multiple health professionals,

investigations to exclude common

often travelling far and wide to access

causes for fatigue is important. It is

specialist services. Finding a health

proposed there is an overlap between

professional with a good understanding

EDS and chronic fatigue syndrome (CFS)

of the conditions can be a struggle. It is

and that indeed in some CFS sufferers

vital that we, the health professionals,

hypermobility signs may go

and employers involved in care

unrecognised. Fatigue in EDS may also

communicate well with each other,

be linked to chronic pain, poor sleep and

creating a patient centred network.

nutrition, deconditioning,

dysautonomia, GI and GU disorders, psychological issues and mast cell disorders.

After all, a well-oiled team of clued-up health professionals is really required to give the best possible support for the next Laura that comes into your clinic.

In closing

If you are interested in learning more

The challenges facing people with

about Hypermobility and EDS the EDS

hypermobility spectrum disorders and Ehlers Danlos syndrome can be considerable and wide ranging. They

Society offer patient information and further training for health professionals.

I would also highly recommend this recently released masterclass article.

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17

The Value of Physiotherapy Input into Lon

By Colette Owen BSc MSc HCPC MCSP Clinical Director at Bespoke Wellbe

Introduction

L

ong Covid, or Post-COVID 19 syndrome, is defined as symptoms that persist for more

than four weeks after the first suspected COVID-19 infection that are not explained by something else (NICE guideline NG188, Oct 2020).

Recent stats from the REACT project at Imperial College, London suggest that over 2 million UK adults are living with Long Covid.

are most likely to be affected, and the

sharing of material from

TUC survey of over 3 500 people report

free-access research and

that of those reporting Long Covid

support groups for those

symptoms, the response from employers

Long Covid and those in

has been varied with 52% experiencing

providing services.

some form of discrimination or disadvantage.

who are living with Long

around for that long. Long Covid was

referring to research evi

starting to be recognised in June,

as possible, the author's

2020 (Carfi et al 20) with NICE

providing a virtual-Long

guidelines published in December 2020.

will also be shared.

Studies suggest that Long Covid can

is limited understanding of how Long

occur regardless of the intensity of the

Covid presents and how best to manage,

initial Covid-19 infection, with the

or even recover from. As a patient with

mechanism still relatively unknown.

Long Covid said “It’s not like I’ve

Hypotheses include cellular metabolic

broken my leg. Doctors and others know

dysfunction (Miller et al, 20), viral

what to do with a broken leg”.

hyperactive immune response (Afrin et al, 20).

Physiotherapists are well-placed to lead and provide Long Covid interventions.

Physiotherapists promote a holistic

Long Covid can affect all body systems,

view, recognising the impact of multi-

with the most commonly reported being

physical systems and mental health on a

fatigue, chest pressure/ pain,

person's health. Physiotherapists are

breathlessness, loss of taste and smell

trained in recognising and managing

and difficulties concentrating (“brain

acute and long term conditions from

fog”) (ONS, 2021; Ziauddeen et al,

Neurology to Respiratory to

2021). Symptoms can overlap, relapse

Musculoskeletal systems and everything

and return often with no obvious

in between.

triggers.

Physiotherapists are adaptable and can

65% of those surveyed by the Office of

see the bigger picture, and with other

National Statistics report an adverse

healthcare professional groups, have

impact on day to day activities. This

been quick to respond during the Covid

could be from having a shower to

pandemic. One positive from the

attending work. People of a working age

pandemic has been the easier access and

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Winter 2021

Long Covid support for w

Covid-19 and Long Covid have not been

Being a new condition does mean there

persistence (Hu et al, 20) and continued

The article will focus on

Providing Long Support

In a very short space a lot we know about L however there is also we do not.

ng Covid Support

eing

m webinars to

d the plethora of

e living with

n healthcare

n Physiotherapy

work-age people

g Covid. Whilst

idence as much

s experience of

g Covid service

g Covid

of time, there is Long Covid, a great deal

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What we do know is that the Long Covid

important component in the

presentation:

management of many Respiratory,

• does not seem to always be dependent on the severity or experience of the acute Covid-19 infection.

• can fluctuate and affect all body systems, often with no discernible physical evidence.

• with this, Long Covid symptoms might not be related to the virus, and must

be checked out

Musculoskeletal and other health conditions (Bott et al 2006; NICE Low Back pain; NICE Rheumatology) and with that multi-system approach, many Physiotherapists are able to provide Long Covid support.

With fatigue and shortness of breath being the most reported Long Covid symptoms, we shall explore how Physiotherapy can provide valuable

• can trigger other conditions such as POTS

input.

It is important to note, with many

• can be affected by identifiable triggers

people having managed their acute

such as lack of sleep, another illness,

Covid symptoms without accessing

or just come and go

healthcare, when managing their Long

And that’s before we acknowledge the effect of a person's beliefs, experiences and knowledge about health and

Covid symptoms, you may well be the first healthcare professional they have seen.

themselves.

Shortness of Breath

Due to the varied presentation of Long

Breathlessness (dyspnoea) is a

Covid, a “one size fits all” approach is

debilitating symptom leading to a

not recommended. This not only refers

negative effect on quality of life,

to the interventions being provided but

function, and wellbeing (Spathis et al

how they are being provided too.

2017). Breathlessness could be caused

There is also huge debate on how Long

by cardiac, respiratory, or other causes

Covid should be managed, or even recognised, within healthcare and the wider social landscape, such as employment and return to work. The

such as anxiety. Those with Long Covid can present with dysfunctional breathing, an umbrella term for describing a group of breathing

recent NICE publication on ME and

disorders (Boulding et al 2016).

graded exercise highlights how

Dysfunctional breathing patterns

healthcare has disparately managed

include: breathing too deeply and/or too

long term conditions for years,

rapidly (hyperventilation) or erratic

particularly those conditions with no

breathing interspersed with breath-

easily identifiable physical cause. We are

holding or sighing and can be

not only managing the beliefs and

psychologically or physiologically based

experiences of those living with Long

(Jones et al 2013).

Covid but those of our healthcare professionals too.

tightness, dizziness and tremor, again

Physiotherapy is recognised as being an

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Symptoms include breathlessness, chest

Winter 2021

commonly seen in Long

There is a debate on Covid sho managed recognise healthcar wider soc landscape employm return to w

also huge n how Long ould be d, or even ed, within re and the cial e, such as ment and work

Covid. Unexplained breathlessness and

many presenting with symptoms

“air hunger” are predominant symptoms

suggestive of dysfunctional breathing,

of dysfunctional breathing (Gardner,

Physiotherapy would be a recommended

1996) and again seen in those living

intervention (Motiejunaite et al 2021,

with Long Covid. It should be noted

Your Covid Recovery, NHS, 2021)

that these symptoms can also be associated with other conditions such as POTS (Reilly et al 2020).

It is well recognised that the anxiety (or fear) of breathlessness can augment the perception of breathlessness (Spathis et

As well as a robust subjective

al 2017). Anxiety is reported as a

questionnaire, a Physiotherapy objective

common symptom of Long Covid and

assessment should include, where

understandably so: the fear of what

possible, respiratory rate, auscultation

might be, multi-layered symptoms to

and observing breathing patterns (e.g.

name but two. It is encouraged that all

chest wall movement, nasal breathing,

Long Covid services consider including

inspiration/ expiration volume).

self-reported anxiety and depression

Recognised self-reported questionnaires such as Nijmegan and MRC Dyspnoea Scale are easy to complete and useful in establishing hyperventilation and

scales such as GAD-7 (Spitzer et al 2006) and PHQ-9 (Kroenke et al 2001) in order to provide appropriate support and education.

dyspnea respectively.

Fatigue

Physiotherapy treatment would focus on

Fatigue is commonly reported as a

two areas: education and breathing retraining.

Education includes the physiology of dysfunctional breathing and breathing control, with the effects external factors can have such as mood and lifestyle

symptom of Long Covid and can be hugely debilitating. It should be recognised that fatigue and being deconditioned are two different things and are managed as such.

(Reillly et al 2020).

Deconditioning can occur after a

Breathing retraining would include

period of inactivity or from a

breathing control (nasal breathing,

sedentary lifestyle: the longer the

normal respiratory rate, diaphragmatic

inactivity the more severe the

breathing, inspiratory/ expiratory ratio)

deconditioning (Elsevier Patient

with the aim to slowly and progressively

Education, 2021). It can make you

increase tolerance of the imposed

feel tired, weak and decrease your

breathing pattern and rate (Reilly et al 2020, Bott et al 2009).

ability to be active with recognised treatments including aerobic and

The above are well recognised

strength exercises (Haseler et al

Physiotherapy techniques and used

2019). The tiredness and other

widely in many Respiratory patients

from COPD to asthma. Their impact on Long Covid has, to my knowledge, not been published as of yet, however with

symptoms associated with being

deconditioned behave within normal parameters, that is, recovery is short with strength and fitness improving

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by adhering to a continued

rehabilitation programme (Falvey et al 2015).

activity due to lack of energy • Extreme and persistent tiredness, weakness, or exhaustion of mental

This is a good moment to remind

and/or physical origin that is not

ourselves of the differences between

relieved by rest or sleep

physical activity and exercise.

Physical activity is “any bodily movement produced by skeletal muscles that results in energy expenditure” whereas exercise is a subsection of activity, and defined as “planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness” (Caspersen et al 1985).

Before providing any kind of physical activity or exercise-based rehabilitation, it is important that risk stratification is completed to screen for cardiac impairment (Salman et al, 2021; World Physiotherapy, 2021). There is evidence of cardiac injury post Covid -19 infection (Imazio 2021), regardless of the severity of the acute Covid infection (Dennis et al, 2021), and those with Long Covid

can present with a disproportionate breathlessness on exertion; inappropriately increased heart rate;

• unpleasant physical, cognitive and emotional symptoms described as a tiredness not relieved by common strategies that restore energy.

(NICE, Oct 2021) A common side effect of fatigue is Post Exertional Malaise (PEM), an abnormal reaction of the body when too much energy, physical, cognitive or emotional, has been expended (World Physiotherapy, 2021). PEM is commonly seen in chronic fatigue conditions such as Myalgic

encephalomyelitis (ME).

PEM symptoms include a general feeling of malaise, fever, “brain fog”, nausea, diarrhoea, widespread body pain and exercise intolerance (NICE guideline NG206, 2021). Symptoms can present up to 48 hours after the activity and can last for days or even months (Stussman et al, 2020). The

variances of how the PEM presents, i.e. how much activity is required, does seem to be variable and

and chest pain. Screening is of

individual to the person.

particular importance for those with

In managing fatigue, it is important

physical jobs and indeed, with any

to reduce the PEM baseline

increase in rehabilitation, would

tolerance; as once the baseline is

suggest continued monitoring for

raised (from illness, over-expending

cardiac signs.

energy), it takes much less activity

Fatigue can be defined as

to trigger a PEM response (Stussman

• exhaustion during or after usual activities, or unable to start an

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et al, 2020).

The management of Long Covid

The manag Long Covid is based up important completed and chroni syndrome

gement of d fatigue pon work d in ME ic fatigue

fatigue is based upon important

and problem solving, can offer

work completed in ME and chronic

valuable guidance in this trickier-

fatigue syndrome. There has been

than-it-sounds concept. Pacing is

much controversy regarding graded

defined as breaking down any

exercise and fatigue with a delay in

activity to make them more

the revised NICE guidelines for ME

manageable, interspersed by rest

and chronic fatigue syndrome. There

and relaxation (World

is evidence that graded exercise

Physiotherapy, 2021). The key aim

programmes, that is fixed

being to complete the activity

incremental increases in the time

without any exacerbation of

spent being physically active, can

symptoms (Physiosforme).

exacerbate PEM. This includes exercise programmes traditionally used for deconditioning which often include aerobic and strength exercises.

Activity diaries can be useful in establishing patterns in emotional, cognitive and physical activities and their effects on fatigue. This would include sleep patterns and rest. The

WHO recommends that Long Covid

diaries can be particularly helpful

Rehabilitation should include

considering that fatigue can occur

education on resuming activities at

up to 48 hours post energy

“an appropriate pace that is safe and

expenditure.

manageable for energy levels within the limits of current symptoms and should not be pushed for postexertional fatigue.” (WHO, 2021) This is not the time to “push on through''.

During exercise, it is seen that those with chronic fatigue present with “oxidative impairments”, that is a disruption of the aerobic system during activity. This may explain why there is often a reduced exercise

Physiotherapists can provide

tolerance in those with fatigue (Todd

support for those with fatigue.

et al 2010). Heart rate monitoring is

Energy management is key and often

a rehabilitation approach in which

it is very difficult to establish what

heart rate at rest and during activity

might be triggering the fatigue, from

is used. By using heart rate

physical to cognitive and emotional.

wearables or manually taking heart

It is important to remember that

rate, it allows the individual to be

fatigue is individual to the person

aware of their heart rate and pace

with their own triggers and levels of

accordingly avoiding triggering an

energy expenditure.

anaerobic response (Todd et al

Planning, pacing and prioritising

2010).

remain the cornerstone of fatigue

It can be challenging to manage and

management, and Physiotherapists,

recognise the energy expenditure

with their background in goal setting

from emotions and cognitive tasks.

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The management of Long Covid fatigue is based upon important work completed in ME and chronic fatigue syndrome.

However, the concept of “energy spoons” or “energy envelopes” is a helpful way for those with fatigue to moderate their energy, but also to

explain to others how fatigue works.

Essentially, you have enough energy, in the form of spoons or an envelope, to expend each day.

Establishing how much energy activities will take allows the individual to self monitor and regulate, leading to better

Conclusion Physiotherapists can provide valuable input into the support of those living with Long

Covid. Taking a holistic review, and utilising multi-system skills, Physiotherapists are able to assess, advise and support not only through recognised Physiotherapy skills but also through change behaviours and effective signposting.

management of their fatigue

Living with Long Covid can be

(Miserandino 2003; Jason et al 2013).

debilitating, frustrating and

All these fatigue-management strategies promote self-management by self-monitoring and selfregulating.

worrying. It is important, whatever our profession, that we acknowledge the impact of Long Covid on the individual and offer considered support based on the current evidence base.

Colette Owen is the Clinical Director at Bespoke Wellbeing, an award-winning Occupational Health

Physiotherapy company which provides virtual and face-to-face Physiotherapy, Ergonomics, Occupational Health and Long-Covid services.

Colette qualified over 20 years ago and has worked extensively within the NHS, Private and Corporate in clinical, managerial, academic and leadership roles. Clinically, Colette has vast experience in musculoskeletal disorders, long-term condition management and chronic pain.

The Bespoke Wellbeing Long Covid programme was launched in February 2021 to support those living with Long Covid and returning to the workplace.

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Combatting fatigue!

By Danny Clarke

O

ccupational Health services

could be a very real and detrimental

are in demand with the

element of our working and personal

pandemic demonstrating how

lives.

useful the speciality is to all organisations, reports the Faculty of Occupational Medicine.

Trying to keep up can lead to a feeling that we are struggling to catch up or keep on top of everything, especially as

So, how exactly can we combat it, especially when those social demands may be increasing as Christmas draws nearer?

Firstly, what is fatigue?

our one whole self includes both home

Fatigue is described as a feeling of

and work. Trying to keep the balance of

constant tiredness or weakness, which

family, deadlines, health, socialising,

can be physical, mental, or a

daily tasks, and the demands of work

combination of both and is not relieved

can be tricky sometimes, especially in

by sleep.

today’s world that never seems to be fully ‘off’. If we aren’t careful, fatigue 26

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Winter 2021

Physical tiredness and mental fatigue

can occur due to a lack of sleep causing

to be addressed urgently

difficulty concentrating. Evidence

Long hours can lead to burnout as noted

suggests driving whilst tired can be as

in a 2016 study which reported “long

dangerous as drink driving, with obvious

working hours are correlated with

consequences. As more and more

burnout when working over 40 hours per

Occupational Health and Safety

week and is even stronger when working

professionals, amongst other

over 60 hours per week.

professions, start to return to the

Overworking can lead to a risk of heart

workplace, it is even more important

disease and stroke, regardless of

that we look to combat fatigue and

industry. However, overworking doesn’t

tiredness.

always mean achieving more, as is

Even if we aren’t driving for work, did

explained in a Forbes article ‘How to

you know that there is a form of fatigue

work less and get more done!’ Forbes

called ‘digital fatigue’, referring to mental exhaustion from overuse of digital technologies (ring a bell anyone?).

It’s likely that most of us have experienced fatigue at some point before, but factoring in the pandemic

describes the importance of rest but for It might seem counterproductive, but it can take more energy to rest than it can to stay fatigued.

some people, rest may seem a waste of time! Perhaps this is because there is a notion that activities such as watching TV and sleeping are the only forms of rest, however, these are simply forms of passive rest. It’s active rest that can

and remote working, it’s probably more

often make the most significant

familiar than we’d like it to be and even

difference.

start to consider it as the “new norm”.

Stop and think for a moment. When was the last time you truly stepped away from it all and had proper rest?

Sleep isn’t rest Often, our response to feeling fatigued is to say that we just need a full night’s

What is active rest?

Rather than viewing rest only as an ‘absence of work’, active rest is the more engaging alternative that can provide us with some much-needed restoration.

There are physical, mental, and social forms of active rest.

sleep. It’s essentially the ‘turn it off and

Physical rest could be a 20-minute walk

on again’ for humans, after all. However,

that not only releases endorphins, but

though sleep might address a physical

also a protein called Brain-Derived

symptom of fatigue such as physical

Neurotrophic Factor (BDNF). BDNF is a

exhaustion, other elements of fatigue

protein that protects and repairs your

are unlikely to be eliminated by sleep

memory neurons as you exercise. BDNF

alone. What we truly need is rest, which

is behind the sudden clarity we can have

can seem much harder to implement

after exercising, which helps us to feel

and conceptualise than sleeping is.

at ease and recall our memories more

One consideration is a culture of

overworking, a competitive culture that includes having no work-life balance.

clearly. Confirmed by the 2016 study,

physical activity helps reduce the risk of burnout.

Any organisational culture in which

Yoga is another form of active physical

fatigue is more of a status symbol needs

rest, which can reduce stress, relieve ioh.org.uk

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anxiety, decrease lower back pain,

relaxing in isolation or socialising with

stimulate brain function, and prevent

others? For some of us, making enough

heart disease.

space to interact in any capacity with

Breathing exercises are a form of physical rest that can be easily implemented throughout your working day as well, from square breathing to some good old fashioned deep breathing, which can also help to prevent those midday yawn marathons.

others is essential for our wellbeing. For others, social burnout can mean that rest is more about planning days to align with energy levels, rather than becoming overwhelmed quickly, especially during periods such as Eid, Diwali and Christmas.

Keeping track of our capacity for

Figure 1. ScienceDirect – January 2020 Mental rest is also a useful tool for

socialising and understanding our

those of us who found ourselves reading

individual needs, will help us to

the same line of an email ten times or

recognise our capacity and manage our

more! Turning off devices and opting

social rest activities.

for meditation is a form of mental rest as is journaling, a popular option. Both can provide a sense of control, by focusing on the now. Or, with the latter, utilised for detailing all thoughts, as a kind of catharsis at the beginning or end

of your working day.

Rest is essential for our health No matter which way you choose to rest, one thing is certain – we need rest to be healthier, happier, and to work well.

Overworking can lead to burnout,

Social rest is entirely dependent on the

whereas deliberate, intentional rest can

way that we like to recharge, i.e., either

provide us with a host of physical,

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Winter 2021

mental, and overall health benefits.

Rest can mean planning our holiday times to give us regular periods away from work, perhaps each quarter, it can be a five-minute breathing exercise or a

bed regularly at 10 pm could be lowering

their risk of cardiac disease! (BBC) Choosing your rest type could be one or all, this is really down to your preference but don’t forget sleep!

long walk with a friend. However, it always includes getting sufficient sleep!

In a small study from Stanford University, a basketball team improved

Danny Clarke CMIOSH, Founder of Simply People

their shooting accuracy by 9% when they increased their sleep by 5 to 7 hours a week. Without enough sleep, say the Sleep Foundation, the brain cannot function properly, impairing our ability to concentrate, think clearly, and process memories and those who go to

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Health and Wel

15th - 16th M

Professor Dame Carol Black

One of the things I’m most looking

always great to learn from people’s

forward to in the new year is being able

personal stories and this year will be no

to meet in person the colleagues and

exception. As a survivor of a forced

friends we have made over the past 16

marriage, Bal Kaur Howard shares her

years of running the Health and

own harrowing story and explains how

Wellbeing at Work event at the NEC.

employers can support victims of

Whilst our virtual event in March 2021

domestic and honour-based abuse in the

was a resounding success, nothing really

workplace. Men can also be victims of

beats the buzz of 4000 delegates over

abuse and Mark Brooks OBE offers a

two days coming together to exchange

greater understanding of the barriers

ideas, learn from best practice and catch

they can face and how to better support,

up with fellow occupational health

recognise and signpost them.

professionals.

This year we have developed an exciting programme that reflects the seismic change that has transformed the way we work and the environment we work in.

We live in disruptive times and rebuilding the resilience and wellbeing of employees as they return to work will Professor Neil Greenberg

Dr Chami Rathmalgoda

be paramount. Professor Neil Greenberg

It is heartening to see that both

returns to headline our new Building

Government and employers are starting

Resilience programme, with Dr Noreen

wake up with regard to women’s health

Tehrani discussing the role of

issues and we are delighted to announce

psychological surveillance in building

the launch of a new Women’s Health

resilience. Mental health continues as a

programme this year. Henpicked’s

growing burden on employees and

Deborah Garlick joins forces with enei to

businesses alike, with financial

provide an update on breaking the

instability, job insecurity and domestic

menopause bias, highlighting potential

abuse all on the rise. Jaguar Land Rover

legislation changes and what this might

have tried multiple interventions to

mean for employers. Optima Health’s

support employees, and it’s CMO Dr

Columba Urey discusses the impact of

Steve Iley offers an insight into what did

menopause and peri-menopause on

and didn’t work and how to deploy best

mental health within a work context,

practice in your own organisation. It’s

together with some practical workplace

llbeing at Work

March 2022 strategies to manage this. Atkins

have had to adapt their approach post-

Global’s Jennifer McClellan teams up

COVID, especially workplace

with Hallam’s Natasha Knowles to offer a

spirometry. Guy’s and St Thomas’ Dr Ali

personal and professional perspective

Hashtroudi has been responsible for

on pregnancy loss, whilst See Her

developing and implementing their

Thrive’s Clare-Louise Knox looks at how

Long-COVID clinic dedicated to

to recognise the signs and symptoms of

NHSstaff and shares his team’s

Premenstrual Dysphoric Disorder, how it

experiences as well as a glimpse into

can affect employees and what support

future challenges. Health Psychologist

employers should provide. Transport

Dr Julie Denning profiles some

for London’s Dr Chami Rathmalgoda

innovative interventions to enable

profiles TfL’s management of employees

employees with Fybromyalgia to return

Dr Steve Ilay

to work while sleep expert Dr David Lee examines the correlation between LongCOVID and sleep disorders and how we

can help employees to overcome these.

Also look out for iOH President Neil Loach discussing the benefits of Clinical Supervision and the role this plays in enhancing clinical outcomes and clinical with endometriosis and Barbara Wilson

staff retention.

shares her personal story of working

We are really looking forward to welcoming you back to the event in March so be sure to visit www.healthwellbeingwork.co.uk to view the whole programme – registration is now open with early bird rates available.

with breast cancer.

Many employers are facing the inevitable challenge of managing employees with Long-COVID. Professor Paul Cullinan’s Lungs at Work team draw

Neil Loach

upon their experience as the UK’s busiest occupational lung disease

Lauren Sterling

service, covering the breadth of occupational respiratory issues within the pandemic, from detection and surveillance, assessment and diagnosis through to short and long term management. They explain how they

Deborah Garlick

What are the respiratory implications of COVID-19?

By Charlene Mhangami, Vitalograph, UK Application Specialist Clinical presentation COVID-19 is mainly spread by respiratory droplets, transmission can occur from a symptomatic or asymptomatic person. In those who are

symptomatic the most common symptoms are highlighted in figure 1.

About 80% of people who contract COVID-19 get mild to moderate symptoms such as dry cough or a sore throat, some may present with pneumonia, a lung condition which

affects the alveoli. Approximately 14% of people get severe symptoms and 5% end up with very severe symptoms1.

How does it end up in the respiratory system?

COVID-19 can affect both the upper and lower part of the respiratory tract. The virus meets the mucous membranes that lines the nose, mouth, and eyes. The virus enters a healthy cell and uses the cell to multiply the virus and the infects nearby cells. As the cells are infected, the lining in the airways become irritated and inflamed as the immune system begins to fight back, the more severe the infection becomes the more it spreads in the respiratory tract and where the problems in the respiratory system begin to arise.

Effect on the lungs COVID-19 can cause complications in the lung such as pneumonia, this where the lungs become filled with fluid and inflamed leading to breathing difficulties. The pneumonia that COVID -19 causes affects both lungs. When someone contracts pneumonia caused by other diseases such as flu, they may recover without lasting lung damage, however the pneumonia associated with COVID-19 can be severe, even after recovery from the disease, the lung injury may take months to improve.

Figure 1 Symptoms of COVID-192

When the alveolus within the lungs gets filled with fluid it limits the gas exchange process causing symptoms such as dyspnea and cough Normally the

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Winter 2021

relationship between capillaries and the

AT II cells and flood the alveolus (figure

alveolar epithelium is closely connected.

2).

The alveolar epithelium (which covers

In more severe cases of COVID-19,

95% of the alveolar membrane) contains

where pneumonia has progressed

Alveolar Type II (AT II) cells. COVID-19

further the capillaries leak more fluid

infects AT II cells which normally would

into the alveoli. Overtime, this leads to

function to secrete pulmonary

acute respiratory distress syndrome

Pathological changes in the lung parenchyma due to COVID-19. (A) Normal alveolus surrounded by capillaries containing red blood cells. Oxygen is exchanged with carbon dioxide in the capillaries. The alveolar membrane contains Type I and Type II cells. (B) Moderately infected lung. Alveolar Type II cells are inflamed resulting in reduced pulmonary surfactant. Surface tension and pressure increase inside the alveolus affecting the gas exchange. Vasodilation of the capillary occurs resulting in release of inflammatory cytokines and accumulation of protein-rich fluid inside the alveolus. (C) Severely infected lung, alveolar type II cells become more inflamed, resulting in complete loss of pulmonary surfactant and scar tissue on the alveolar surface begins to form, inflammatory cytokines are increased, and more protein-rich fluid accumulates inside the alveolus. Gas exchange process is affected resulting in difficulty breathing3.

Figure 2

surfactant: primarily responsible for

(ARDS) which is a form of lung failure.

reducing the surface tension between

Patients with ARDS are often unable to

the tissue in the alveoli of the lungs to

breathe on their own and may require

prevent atelectasis which is collapse of

ventilatory support to help oxygenate

the lung. However, COVID-19, kills the

the body. Another possible complication of severe COVID-19 is ioh.org.uk

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sepsis, this occurs when an infection

Although those who had pre-existing

within the lung spreads through the

comorbidity such as interstitial lung

blood stream causing tissue damage all

disease (ILD) was independently

over the body. The cooperation between

associated with a decreased FEV1 and

the organs falls apart, in some cases

those with cystic fibrosis were

even after recovery from sepsis a patient

associated with having a deteriorating

can have lasting damage to the lungs

FVC when comparing the pre and post

and other organs.

infection PFT. Only increasing age was

(Borczuk et al.,2020) performed a multi—institutional autopsy cohort study in Italy and New York, to evaluate lungs of 68 patients who had received an autopsy following the contraction of COVID-19. They looked at several

independently associated with a reduction in TLC and DLCO pre and post infection. Overall, the study is

suggestive in those who don’t have underlying disease there isn’t a difference between pre and post PFT.

“Pulmonary functio

noninvasive tests th

the lungs are workin

measure lung volum

compartments of the respiratory system

Another study by (Eksombatchai et al.,

(airways, alveolar walls, airspaces, and

2021) looked at spirometry, six-minute

vasculature) to observe the extent of

walk test and chest x-ray among those

COVID-19. From this they identified

who had recovered from COVID-19. The

COVID-19 as heterogenous meaning it

study included 87 patients who had

affects various parts of the respiratory

recovered and been discharged from the

system. They found evidence of

infection. Testing was performed on day

bronchitis, alveolar damage, and

60 after the onset of symptoms. They

subjects at risk of lu

vascular injury.

were 35 men and 52 women, 45 patients

“DLCO – Diffusing l

Usefulness of testing

had mild symptoms, 35 had non-severe pneumonia and 7 had severe

Various studies have been performed to

pneumonia. When evaluating test data

assess how much of the damage caused

15 patients (17.2%) had abnormal

by COVID-19 can be picked up by

spirometry, with 8% having a restrictive

pulmonary function testing. A

defect and 9.2% having an obstructive

retrospective multi-center cohort study

defect. The patients with abnormal

by (Lewis et al,2021) looked at patients

spirometry where mainly those with

who had a lung function test pre-

severe pneumonia. The other tests

infection and post-infection within one

shown those with severe pneumonia had

year of the infection, during March 2020

shorter mean 6-min walking distance

and November 2020. They tested a total

and chest abnormalities visible on x-ray

of 80 patients with an even split

was present in those with severe

between males and females, who had a

pneumonia.

mild to moderate COVID-19 requiring hospitalization. The main findings where there was no difference between pre and post-PFT data, when looking at

spirometry, DLCO and lung volumes.

They observed there was no difference in PFT data when analyzed by hospitalization and disease severity.

34

OH TODAY

Winter 2021

A study by (Wu et al., 2021) looked at the consequences of COVID-19 in 83 patients that were admitted with severe case but did not require mechanical

ventilation. Patients included had no underlying respiratory conditions.

Patients had followed up hospital at 3 months, 6 months, 9 months, and 12

of flow, and gas exch

“Spirometry, also kn

lung volumes, is use

forced expiratory flo

volumes. It is the m

pulmonary function

carbon monoxide. A “Gas Transfer” this

extent to which oxy

the air sacs of the lu

blood. It is one of th

valuable tests of lun

“Lung volumes mea

known as static lung

measure or calculate

capacities of air with

cant be measured by as FRC.”

months after discharge from hospital.

symptoms as those with severe cases

During the visits they had a full PFT test,

requiring ventilation may have high

blood tests, CT scan, 6-minute walk test

levels of deconditioning Follow up care

and filled out the medical research

should be considered for those patients

council dyspnea scale (MRC). Overall,

with persisting clinical symptoms, this

they observed improvement

may include serial measurements of

What does the future look like?

on tests (PFTs) are

hat show how well

ng. The test

me, capacity, rates

hange.”

lung function, echocardiography, and CT scans of the chest.

Other treatment options are being

A patient’s recovery and long -term lung

investigated. An observational study by

heath is dependent on what kind of care

(Myall et al., 2021) looked at progression

they get and how quickly, especially

of persistent inflammatory interstitial

those with are critically ill with the

lung disease (ILD) associated with

condition. The prognosis is

COVID-19 and whether a corticosteroid

approximately 25 to 50 percent which is

such as prednisolone is effective in

mainly caused by severe ARDS, mortality

nown as dynamic

treating pneumonia associated with the

can be higher in those with existing lung

ed to measure

disease. The outcome was early

conditions. The highest mortality rates

ow rates and

intervention with corticosteroids is well

occur in those 65 years and older (Yanez,

tolerated and can improve lung function

Weiss, Romand and Treggiari, 2020).

as they observed increase in DLCO and

most used

n test to evaluate

ung disease.”

lung capacity for

Also known was

For those who recover from the disease some people may still present with prolonged post-acute symptoms, often described as “Long Covid”. The

test measures the

symptoms are mainly respiratory

gen passes from

(breathlessness, cough, chest-tightness,

ungs into the

chest pain ), but also include neurology,

he most clinically

cardiovascular complications, and

ng function.”

chronic fatigue. It has been suggested

asurements also

that abnormalities are still visible in

FVC. As this is a novel virus, further

research is still needed as to whether the effects of COVID-19 are permanent or whether they will heal over time.

“Post COVID-19 or “Long Covid” syn-

g volumes,

those who are not critically ill4.

drome is defined signs and symptoms

e the volumes and

When looking at long covid and

hin the lungs that

assessing symptoms overtime with

infection consistent with Covid-19,

y spirometry, such

pulmonary function testing. Spirometry indices appear to be preserved but DLCO abnormality has been identified on

that develop during or following an continue for more than 12 weeks and are not explained by an alternative diagnosis.

follow-up lung function, present in 2030% with mild to moderate disease and 60% of those with severe disease. Also, reductions in total lung capacity were commonly reported (Thomas, Price and Hull, 2021).

Clinical rehabilitation is being considered in helping patients improve

ioh.org.uk

OH TODAY

35

References

Mallea, J., Baig, H. and Patel, N., 2021.

1. https://www.who.int/docs/defaultsource/coronaviruse/situationreports/20200306-sitrep-46-covid19.pdf

COVID-19 and the effects on pulmonary function following infection: A retrospective analysis. EClinicalMedicine, 39, p.101079.

2. Clerkin, K., Fried, J., Raikhelkar, J., Sayer, G., Griffin, J., Masoumi, A., Jain, S., Burkhoff, D., Kumaraiah, D., Rabbani, L., Schwartz, A. and Uriel, N., 2020.

COVID-19 and Cardiovascular

Disease. Circulation, 141(20), pp.16481655.

Myall, K., Mukherjee, B., Castanheira, A., Lam, J., Benedetti, G., Mak, S., Preston, R., Thillai, M., Dewar, A., Molyneaux, P. and West, A., 2021.

Persistent Post–COVID-19 Interstitial Lung Disease. An Observational Study of Corticosteroid Treatment. Annals of the

3.Wang, S., Li, Z., Wang, X., Zhang, S.,

American Thoracic Society, 18(5),

Gao, P. and Shi, Z., 2021. The Role of

pp.799-806.

Pulmonary Surfactants in the Treatment of Acute Respiratory Distress Syndrome in COVID-19. Frontiers in Pharmacology, 12.

Thomas, M., Price, O. and Hull, J., 2021.

Pulmonary function and COVID19. Current Opinion in Physiology, 21, pp.29-35.

4. Nice.org.uk. 2021. [online] Available at: <https://www.nice.org.uk/guidance/ ng188/resources/covid19-rapidguideline-managing-the-longtermeffects-of-covid19-pdf-51035515742> [Accessed 29 November 2021]

Wu, X., Liu, X., Zhou, Y., Yu, H., Li, R.,

Zhan, Q., Ni, F., Fang, S., Lu, Y., Ding, X., Liu, H., Ewing, R., Jones, M., Hu, Y., Nie, H. and Wang, Y., 2021. 3-month, 6month, 9-month, and 12-month respiratory outcomes in patients

Borczuk, A.C., Salvatore, S.P., Seshan,

following COVID-19-related

S.V. et al. COVID-19 pulmonary

hospitalisation: a prospective study. The

pathology: a multi-institutional autopsy

Lancet Respiratory Medicine,.

cohort from Italy and New York City. Mod Pathol 33, 2156–2168 (2020)

Yanez, N., Weiss, N., Romand, J. and Treggiari, M., 2020. COVID-19 mortality

Dhont, S., Derom, E., Van Braeckel, E.,

risk for older men and women. BMC

Depuydt, P. and Lambrecht, B., 2020.

Public Health, 20(1).

The pathophysiology of ‘happy’ hypoxemia in COVID-19. Respiratory Research, 21(1).

Lewis, K., Helgeson, S., Tatari, M., Mallea, J., Baig, H. and Patel, N., 2021.

COVID-19 and the effects on pulmonary function following infection: A retrospective

analysis. EClinicalMedicine, 39, p.101079.

Lewis, K., Helgeson, S., Tatari, M.,

36

OH TODAY

Winter 2021

Promoting healthy nutrition: an opportunity for occupational health specialists

By Steven Pearson-Brown

H

ealth promotion has been linked to increased productivity, reduced health

risks, and a decrease in healthcare utilisation (Baiker et al) especially important with the current load on the NHS! Occupational Health (OH) has an important role in supporting

organisations through monitoring the health of employees and prevention of ill health (NHS), a public health opportunity and duty. To do this, OH develop and implement programmes 38

OH TODAY

Winter 2021

that support healthy lifestyles, particularly in areas of healthy eating, weight management, physical activity, mental health, and stress management2.

Especially important due to the impact of the pandemic with associated influence on physical and mental wellbeing.

Healthy eating is of particular importance in managing a range of health conditions including prevention and OH professionals play a significant

role in this as testified by Toothaker et

economy through absence, early

al (2018). Enabling employees to have

retirement, and reduced productivity.

the knowledge and skills to make

Estimated costs to the NHS from CVD

healthy lifestyle choices assists with the

are £7.4 billion per year (PHE), with

prevention or management of chronic

T2DM costing £8.8 billion per year

disease which could have a significant

(PHE); collectively costing the UK

impact on an individual at work. Any

industry £31.1 billion each year.

interventions and/or advice in delivering

Employees who consumed a healthy diet

an awareness of nutrition and its role in

had a lower incidence of multiple health

health is a valuable addition to the OH

conditions, including, iron-deficiency

professional’s toolbox.

anaemia, hypertension, dyslipidaemia,

There is a direct link between poor

osteoporosis, T2DM, oral disease,

A Healthy diet (Grodner, et al., 2016) = Balanced calorie intake is an important factor in maintaining a healthy weight and the prevention of obesity and obesityrelated conditions with

• whole grains, • fruits and vegetables, • lean sources of protein (including lean meat and nonmeat products)

• Alcohol • Added Sugar • Saturated and trans fat • Salt

• low-fat dairy

nutritional intake, dietary excess and

constipation, diverticular disease, and

the development and prevention of

some cancers (Grodner, et al., 2016).

several non-communicable diseases,

such as cardiovascular disease (CVD) and Type 2 Diabetes Mellitus (T2DM) (Dudek 2014). CVD and T2DM are two major conditions that are a financial burden on the NHS and the wider

Making every contact count to promote health: During health surveillance, health assessments and preemployment clinical assessments, the ioh.org.uk

OH TODAY

39

calculation of an individual’s body mass

their progression to further

index (BMI) is frequently required as a

complications. Even routine screening

marker of health and potential health

may potentially make the conditions

risks, in addition to the safe deployment

avoidable. Several studies have looked

to undertake a specific task at work.

at nutritional interventions focussing on

This presents an opportunity to discuss

the workplace to improve the health of

nutritional intake with employees.

individuals and promote positive

Many factors impact an individual’s diet

outputs, such as a reduction in

including knowledge, social support,

absenteeism. Since many individuals

finances, and access (Lutz et al 2014).

spend a large portion of their time at

Understanding this and the variety of

work, often eating at least one meal

food and drinks consumed over time in

there, well-planned support can be

settings such as workplaces,

useful to support weight management,

restaurants, and homes,(Reed 2014)

improving healthy behaviours and

alongside the social, cultural, and

prevention of obesity,(Melian et al 2021) and may also serve as a valuable

Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition addresses 3 broad groups of conditions: [1] undernutrition, which includes wasting (low weight-for-height), stunting (low height-for -age) and underweight (low weight-for-age);[2] micronutrientrelated malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess; and [3] overweight, obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes and some cancers.) (WHO)

environmental factors of diet is an

component in occupational health and

important skill for clinicians.

safety (Grimani 2019).

Of course, focusing purely on body

What does this mean

weight would be missing a vital component of the role of nutrition in health as weight is only part of the picture. Indeed, a common misconception is that only underweight people can be malnourished, but malnutrition can happen at any weight.

Whilst non-communicable diseases occur at any weight or intake of nutrients, evidence shows us that early detection can be valuable in preventing 40

OH TODAY

Winter 2021

Incorporating nutritional screening and providing education, as a part of occupational health could provide a valuable tool to support employees to make healthier choices and improve productivity, employee output and quality of life.

Steven Pearson-Brown RNutr. FRSPH. MSc. BSc. (HONS)

INTERVIEW

CHARLIE WAKELEY SPECIALIST COMMUNITY PUBLIC HEALTH NURSE (OH) AND NEWLY APPOINTED DIRECTOR OF STUDENT AFFAIRS FOR iOH

INTERVIEWED BY LYNN PRATT This week I had the pleasure of catching up with Charlie Wakeley, who is also the winner of 2020 iOH Ruth Alston Memorial Award for Excellence in OH Nursing.

How did you get into OH?

Occupational Health Nurse Advisor at

In 2010 I qualified as an Adult Nurse

within OH.

after completing my studies as a mature

student. Prior to this I had gained qualifications in Business & Management. I had left school without any qualifications, so it was a long journey to get to the nursing course. I had wanted to become a nurse since childhood. Shortly after qualifying I spent a little time volunteering for an OH company local to me. I felt that the field complimented my previous experience within the business world and my newly gained nursing skills. I however recognised that I needed to gain a better all round grounding in nursing before making the move. In January 2018 the opportunity presented to move into a Screening Nurse role for an NHS OH service. I jumped at the opportunity and in September 2020 commenced the SCPHN course at Derby University full time.

What are you currently doing?

I have just started a new role as

Huddersfield University. I am excited to start the next chapter in my career

Who and what has inspired you most?

My amazing colleague Julie Dowkes, a Specialist Nurse working tirelessly for the last 17 years within the NHS has been such an inspiration. She always has wise words to offer for any situation and is steadfast in her integrity and unflappable in her approach to any scenario.

Where do you get support from?

I have found iOH and the Facebook forums such as UK Occupational Health Practitioners invaluable for gaining a greater understanding of key issues, reaching out for opinions on certain subjects and generally being part of a bigger network of practitioners within

the field. During the start of the Pandemic access to this support really came into its own, not least to understand that the pressures I faced were not faced alone, but as part of a ioh.org.uk

OH TODAY

41

wider community. I feel creating these

an outlet to ensure compassion fatigue

relationships with fellow practitioners is

is guarded against. In addition to this

vital to ensure ongoing high levels of

the commitment to ongoing regular

care.

reflection about one's own practice I feel

In addition, having formed relationships with my fellow students during the course has been so valuable.

We can raise queries or concerns without feeling silly for asking random questions.

My family, Keith and Beatrice have been with me throughout my course and the pandemic. They have both supported me with encouragement, laughter and celebrations. Our love for the outdoors gives us all a balance to help with our busy lives.

I am excited about plans for greater access to OH for more workers, but we really need to shout about our skills and experience much more to make our voices heard. I feel that working closely with the wider community of healthcare professionals to improve public health is key to seeing the health and wellbeing of the workforce improve. In addition, OH professionals have a role to play in helping leaders to understand the impact of their leadership styles on the efficiency of their workers. As stated by Dame Carol Black in 2008 “Good line management can lead to good health, wellbeing & improved performance”. 13 years on and it still feels that there is still so much work to do on this.

I would like to see a greater commitment to Clinical Supervision

within OH. The difficult subjects that OH professionals have to tackle in their day to day dealings has the potential to leave those practitioners feeling emotionally drained, and there has to be OH TODAY

able to deal with the challenges of the role.

Do you have any advice for those considering going into OH and considering further academic study?

My advice would be to “go for it”, however be prepared for hard work, some tears and a bit of sweat! Being organised will help ease the pain a little

How do you see the future of OH?

42

is vital to ensure we remain current and

Winter 2021

and remember nothing that is worth having comes easy!

I really feel that having some experience within OH before undertaking the course was helpful. OH is so varied from business to business. Coming from an NHS background I have found that staff rarely know the breadth and depth of what is required of an OH nurse.

How can you help student iOH members? iOH has just under 100 student members. My role as iOH Director of Student Affairs aims to support those who are considering OH as a specialty, and those who are currently studying.

Many more OH professionals will be needed in the future and it is vital there is encouragement to get more to enter the sector. If anyone would like to have a chat, please email admin@ioh.org.uk with Student Support in the heading.

Joining iOH as a student member is currently free for the first year and thereafter £10 annually.

Ioh.org.uk OH TODAY 44