Case Study Evaluation and Care Plan Synthesis: Work-Related Musculoskeletal Disorder

Work-related musculoskeletal disorders (MSDs) form a substantial fraction of workplace injuries and compensation claims on behalf of workers (Cimmino, Ferrone, & Cutolo, 2011). Early intervention and prevention play a crucial role in controlling the outcomes associated with MSD. In order to work out effective means of treatment, there is a need to clearly understand the pathophysiological mechanism of MSD (Storheim & Zwart, 2014). The current paper represents a case study evaluation of work-related MSD aimed at creating a comprehensive care plan including disease prevention and health promotion.

Case Study Evaluation

Pathophysiology

The cause of MSDs including lower back pain lies primarily in poor health condition explained by the incongruity between the external load and the capability of the body to resist the biomechanical load and consequential physiological stress (Gore, Sadosky, Stacey, Tai, & Leslie, 2012). Extreme forces are able to trigger numerous pathological physiological processes contingent to the affected tissues. The resultant physiological effect depends on the frequency, duration and magnitude of external load as well as the recovery time. Various symptoms in different body parts depend on the extent to which the physiological processes have progressed (Kaufman-Cohen & Ratzon, 2011). The capability is determined by individual body variables like general health, age, gender, and body type. The capacity also weakens with aging. MSDs result from the activities that entail carrying heavy loads, which can provoke acute injury. The majority of work-related MSDs are caused by making repetitive motions or continuously staying in a static position (Gore, et al., 2012). Furthermore, the activities that do not require excessive force can result in damaging the muscles if the activity is repeated over short durations. A combination of heavy load coupled with repetition further increases the risk of developing MSD.

Signs/Symptoms

The most common symptom of work-related MSDs is pain. Other symptoms of MSDs include swelling, redness, muscle tightness, and stiffness of joints in the affected area. Some people suffering from MSDs also experience reduced sweating of hands, changes in the color of their skin, numbness, and “pins and needles” (Cimmino et al., 2011). Inflammation, reduction in the strength of grip, reduced level of motion, function loss, numbness, tingling, and fatigue are also some of the indicators of MSD. According to the case study, the patient suffers from a number of these symptoms including low back pain, tingling and numbness in the toes.

Progression and Trajectory

The progression and trajectory of MSDs is symptomatic. The stages of MSDs range from mild to severe, with each stage being different based on symptoms. The first stage of MSDs is the early stage, which is characterized by tiredness and aching of the affected area that are likely to be experienced while working physically and disappear when one is not working (Storheim & Zwart, 2014). During this stage, there are no significant changes in the worker’s performance. Other signs experienced during the early stage of MSD include fatigue, mild aching and pain, and soreness of the fingers and limbs affected experienced while working and diminishing when one is not working (Cimmino et al., 2011). The second stage is the intermediate stage, which is characterized by tiredness and aching occurring during early periods of work and continuing when one is resting. Pain, aching and fatigue are experienced immediately when a person starts working and continue when one is having a rest. During this stage, there is a decline in productivity. The third phase is the last stage, which is characterized by weaknesses, fatigue, and aching persisting when one is resting. The person with the MSD also becomes unable to carry out light duties and start suffering from sleep disorder. Even when resting, swelling, pain, and soreness are experienced (Laisné, Lecomte, & Corbière, 2012). As a result, the patient depends significantly on the continued use of medications to relieve pain. Based on the information in the case study, it is evident that the patient is at the last stage of MSD. This is evident by a number of signs such as reduction of productivity since he is not capable of working; having problems with sleeping at night; relying on medications to relieve pain; and persistent pain even when not working.

Diagnostic Testing

The diagnosing of MSDs is based on the patient’s history as well as physical examination. Imaging tests, laboratory tests, and other diagnostic procedures may be needed to confirm the diagnosis. A number of lab tests may be performed when diagnosing MSDs including erythrocyte sedimentation rate (ESR) test, and testing for the level of creatine kinase. The ESR test is used to determine the presence of inflammation whereas the creatine kinase test is used to determine the presence of muscle damage (Mafi, McCarthy, Davis, & Landon, 2013). This lab tests can also be used for monitoring treatment progress. Muscle and nerve tests such as electromyography and nerve conduction studies can also be used in the diagnosis of MSDs. These tests determine whether the nerves attached to the muscles are working properly. X rays can also be used for the detection of bone abnormalities and can be helpful in the evaluation of deformed, painful, and potentially abnormal bone areas. X-rays also help to diagnose deformities, infections, injuries and fractures (Van Middelkoop et al., 2011). A combination of both ordinary and stress x-ray is needed to determine whether injury has caused bone damage.

Treatment Options

The first approach for treating work-related MSDs entails the avoidance of activities that are known to result in the injury, which usually requires work/movement restrictions (Gore, et al., 2012). In some instances, it is recommended to consider changing the job itself. A splint can also be deployed in restricting movements or immobilizing the injured joint. Nevertheless, using splints in work setting requires excessive caution. When a splint is used in a wrong way, they may cause more harm, than benefit. Splints are used mainly for two purposes, which include providing mechanical support for a joint expecting an extreme mechanical load, and restricting the movement of the affected jint (Gore, et al., 2012).

Applying heat or cold helps to relieve pain and accelerate the process of repair. Cold has been established to lessen both swelling and pain and has been recommended for treating inflammations and injuries (Wand et al., 2011). For muscle pain, applying ice is not recommended since low temperature will lead to further muscle contraction. Applying ice is only recommended for muscle pain immediately following the development of the injury, and is recommended to be used only for a few days. Applying heat is effective for relieving muscle pain since heat helps to speed up the flow of blood, which in turn eliminates the buildup of lactic acid (Gore, et al., 2012). However, it is not recommended to apply heat for injuries characterized by considerable swelling and inflammation.

Stretching is beneficial for MSD patients since it facilitates the circulation of blood and lessens tension in muscles (Gore, et al., 2012). Nevertheless, people with MSD should first check it with a physical therapist become embarking on exercising. Moreover, improperly designed physical activity or stretching programs can worsen the patient’s condition.

Anti-inflammatory medications can be used for reducing inflammation and pain (Gore, et al., 2012). The medication and surgery are considered the last option after the failure of other treatment options. As for the patients with MSDs like fibromyalgia, medications are reported to be effective in increasing the levels of norepinephrine and serotonin when taken in low dosages (Mafi et al., 2013). Some of the medications that can be used for inducing sleep and modulating pain and the function of the immune system include Desyrel, Klonopin, and Ambien (Gore et al., 2012).

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A number of therapeutic options also exist for people with MSDs such as resting, non-steroidal anti-inflammatory drugs (NSAIDSs), extracorporeal shock wave therapy, and acupuncture. In the recent years, the therapeutic options for MSDs have expanded significantly with advancements in regenerative medicine. An example is the mesenchymal cell therapy (Cimmino et al., 2011).

Differences between the Disorder and Normal Development

MSDs are pain or injuries affecting the structures supporting the back, neck, and limbs; tendons, nerves, muscles, ligaments, and joints. MSD is considered an inflammatory and degenerative disorder that results in pain and hinders normal activities. MSDs affect various body parts such as the lower and upper back, extremities (hands, feet, legs and arms), shoulders, and neck. The severity of MSDs also varies (Wand et al., 2011). The discomfort and pain associated with MSDs can result in substantial disruptions in daily activities. MSDs are very prevalent and the risk increases with aging. Early diagnosis and intervention play an instrumental role in easing pain while at the same time reducing additional bodily damage.

Physical and Psychological Demands That the Disorder Places On the Patient and the Family

MSDs are a considerable physical and psychological burden for the patient and the family. This burden can be attributed to the impaired function (disability) caused by MSD, which affects the daily-life activities. Because of MSDs, simple household chores and daily activities represent a significant challenge (Van Middelkoop et al., 2011). The patient with MSD suffers due to his/her inability to work and perform physical activities, which can be attributed to physical impairments (Wand et al., 2011). As a result, stress and depression are likely to be experienced because of the patient’s worries about being unable to earn a living for themselves and their families. They are also fearful of the fact that they will be a burden for their family members in terms of physical support. Whereas the burden associated with caring for an individual with MSD has not been vastly studied, existing evidence suggests that it is in fact, substantial. The burden placed on family involves stress associated with the disruption of household routine, restricted social activities, and economic difficulties. Families with an individual suffering from MSD have to make considerable compromises and adjustments, which in turn may hinder other family members from engaging in social relationships and working to the best of their abilities (Gore et al., 2012).

In the case study, the MSD is associated with considerable demands for the patient and his family. First, he is worried about his ability to work. Moreover, the economic costs of treating MSD are also high compared to his annual earnings, and this is further worsened by the lack of healthcare insurance. With respect to the demand placed on the family, the patient’s parents will have to disrupt their activities to take care of him, both physically and probably financially due to the likelihood that he might not be able to return to the same place of work.

Key Concepts that Must Be Shared with the Patient and Family to Achieve Optimal Disorder Management and Outcomes

The emphasis of patient- and family-centered care is placed on engaging patients in the decision-making process related to their care (Mafi et al., 2013). According to the case study, a number of concepts should be shared with the patient and his family members. The first aspect to be shared is the need to change the job or stop working as a roofer altogether. It is evident from the case that the patient’s job involves repetitive heavy lifting, which is worsening his condition. The patient should consider the possibility of changing the job or quitting altogether if he wants to prevent further bodily damage (Kaufman-Cohen & Ratzon, 2011). The second important concept that should be shared with the patient and his family members is related to the access to healthcare services. Currently, the patient virtually lacks access to healthcare services, which can be attributed to lack of insurance coupled with the lack of awareness of the resources in the patient’s community. There is a need to enhance the awareness of the patient regarding the ways of increasing access to healthcare services such as looking for insurance coverage and increasing his awareness of the healthcare services available (Storheim & Zwart, 2014). Also, it is imperative to inform the patient and family members about the treatment options available, which have been discussed earlier. Lastly, the patiennt and his family members should be informed of the risk of hypercholesterolemia, since both of his parents have high cholesterol levels.

Key Interdisciplinary Team Personnel Needed and How This Team Will Provide Care to Achieve Optimal Disorder Management and Outcomes

In addition to MSD, the patient suffers from a myriad of problems that require a multi-disciplinary approach to care. A physician is the first important part of the team. The role of the physician in the treatment plan is focused primarily on making the diagnosis and monitoring the progress of treatment. In this respect, the physician is charged with ordering and performing tests to determine the extent of muscle damage and inflammation in the course of treatment (Gore et al., 2012). The interdisciplinary team also comprises of nurses. Nurses not only play a role in administering care for MSD patients but also educating them about factors and means of prevention. In this regard, the nurse will educate the patient about the risk factors for work-related MSD and preventive measures that can be taken (Gore et al., 2012). Moreover, the nurse must exercise patient- and family centered care when caring for the patient by involving them in the decision-making process. Nurses should also promote safe and optimal function with respect to self-care and mobility. The interventions aimed at promoting comfort and relieving pain are crucial for maintaining function. Essentially, nurses should assist the patient in preventing further injury, lessening the risk of complications, promoting healing, maximizing independence, and encouraging optimal rehabilitation (Cimmino et al., 2011).

Besides improved clinical outcomes, the patient will need support and understanding from family members and friends to help prevent the patient from developing stress and depression due to the likelihood that he will need to change his job (Laisné et al., 2012). In this respect, a psychological therapist will be part of the interdisciplinary team, who will be in charge of organizing group sessions with patients having similar injuries. Group sessions have been found to be an effective psychological support system (Storheim & Zwart, 2014). The counselor will also help in addressing potential stress emanating from the patient’s worries about the outcome of his working disability, problems with his wife, and his perceptions of failure as a husband.

The interdisciplinary team will also consist of a social worker, dietitian, and physiotherapist. The social worker will assist the patient with his social and financial problems that are likely to be caused by lengthy absence from employment and offer advice about retraining and looking for new employment opportunities (Storheim & Zwart, 2014). The dietary habits of the patient are poor; hence there is a need for a dietician in the treatment plan. The role of the physiotherapist will be to help the patient restore function and movement.

Facilitators and Barriers to Optimal Disorder Management and Outcomes

A number of facilitators have been identified from the case. These include lack of any risk factors for MSD; compliance with the prescribed regimen; and care-seeking behavior of the patient. However, barriers to optimal disorder management and outcomes also exist, which include late diagnosis and intervention; reduced access to healthcare; patient’s unawareness of resources in the local community; lack of support base; and psychological problems.

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Strategies to Overcome the Identified Barriers

Since MSD in the patient was diagnosed at its later stages, the emphasis of the treatment should be on preventing further damage to the body and restoring functioning. The reduced access to healthcare and patient’s unawareness of healthcare services will be addressed through patient education, which will be focused on informing the patient of the need to make good use of the available healthcare services and resources (Cimmino et al., 2011). This barrier can be attributed to ignorance; thus, it can be tackled through educating the patient. In order to address the issue of support base, the treatment plan will involve the patient’s parents and friends. Efforts should also be made to include his former wife in the treatment. Moreover, psychological therapy will be incorporated into the treatment plan executed in the form of group sessions with other MSD patients in order to widen the patient’s base for emotional support (Gore et al., 2012).

Care Plan Synthesis

Comprehensive and Holistic Recognition and Planning for the Disorder

This care plan is intended for a specific type of MSD, lower back pain, which refers to a sensation of pain experienced in the intervertebral discs, especially in the lower lumbar, L5-S1, as shown in the lab results of the patient. The lower back pain is attributed to MSD associated with heavy lifting. The lower back pain manifests itself each time the patient is bending. He also reveals other symptoms of MSD including persistent tingling and numbness.

A number of diagnostic evaluations will be carried out for the patient. The first is vertebral X-ray, which seeks to reveal the presence of scoliosis, osteoarthritis, infection, dislocation or fracture (Gore et al., 2012). The second diagnostic test that will be performed is Computed Tomography, which will help determine the underlying disease including the presence of hidden soft tissue lesions surrounding the vertebral column (Cimmino et al., 2011). This test will also reveal any problems in the intervertebral disc. Lastly, ultrasound will be performed to help diagnose the spinal canal narrowing. MRI will also be performed to determine the location and nature of the spinal pathology (Storheim & Zwart, 2014).

A nursing evaluation of the patient will also be performed, which will be focused on the descriptions of the patient’s pain and discomfort including the nature, duration, and frequency. The nurse will also investigate the activities that trigger pain and the muscles engaged during such activities. Information relating to occupational activities will also be gathered with the aim of identifying areas of potential patient education. When conducting the assessment, the posture of the patient will also be observed (Mafi et al., 2013). A physical exam to review the spine curvature and shoulder symmetry will be conducted.

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