Return to Work following Motor Vehicle Accident: A Case Report

Abstract

According to the American Industrial Hygiene Association (AIHA), tests of functional capacity evaluation (FCE) have an insignificant relationship with the actual tasks performed and the on-job assessment is required. Commuting accidents have been an increasing trend. A 34-year-old gentleman was referred following severe traumatic brain injury with cerebral edema and multiple fractures. He was evaluated with the Chessington Occupational Therapy Neurological Assessment Battery (COTNAB) where his visual perception performance has improved. The performance of visual and spoken instructions is within normal limits. He has improved on the upper extremity functional scale measure activities with an affected limb from 60 to 68 and also improved on the lower extremity functional scale from 43 to 51. He managed to cover a distance of 2 km in 42 minutes after a short break and accomplished to climb 200 steps after a mini-break through maximum capacity evaluation. The patient is fit as a clerk after going through various sessions to improve the cognition and function of extremities. FCE is precisely measured behavioral tests and should be inferred from the patient's personal and environmental setting.

INTRODUCTION

Fatality due to road accidents is an increasing trend from 1990 to 2011 in Malaysia, especially among motorcyclists. Commuting accidents were 33,319, 33,314, and 28,579 in 2017, 2016, and 2015, respectively.[1] The Social Security Organization plays a vital role in returning the insured person with an injury to work and curtailing the effect of the injury and disability. According to American Industrial Hygiene Association (AIHA), tests of functional capacity evaluation (FCE) have an insignificant relationship with the actual tasks performed, and hence, the on-job assessment was also performed to match the worker to the job.[2]

CASE REPORT

A 34-year-old gentleman was referred to a rehabilitation center in 2019 following a motor vehicle accident. The diagnosis for this patient was severe traumatic brain injury with cerebral edema. He also sustained open fracture of right midshaft of tibia and fibula (Gustilo I), open fracture of right midshaft of femur (Gustilo II), closed fracture of right distal end of radius, closed fracture of right distal end of radius and closed fracture of right base of third metacarpal bone and also full thickness burn over right lateral shin. He was initially on Ilizarov on the right femur for six months and a tibial external fixator for nine months. Plating and intramedullary nail were fixed for the fractures. The patient has been working as a clerk in a nongovernmental organization since 2016. He occasionally would carry a maximum weight of 5 kg of bunting to give a religious talk. He is required to climb two flights of stairs daily to his office; each flight has 15 steps.

He was assessed using the Chessington Occupational Therapy Neurological Assessment Battery (COTNAB) on November 25, 2019. The results are shown in Table 1. A reassessment of COTNAB was done on January 8, 2020. His visual perception performance has improved, but there was no difference in the performance of construction ability and sensory–motor functional areas with 57 seconds in 3D construction and 5 minutes and 15 seconds in block printing. The performance of visual and spoken instructions is within normal limits as all 12 cards were selected correctly and fulfilled all four sequences in the spoken instruction. COTNAB was used to assess prognosis and also as a therapeutic intervention in this patient using Logico Piccolo Grolier book exercises, geometric sticks, and graded pinch exercises with memory recall exercises.

Table 1:

Assessment using COTNAB

Items	Task (seconds)	Ability	Time	Overall performance
1. Visual perception
i) Overlapping figure test	86	Normal	Impaired	Borderline
ii) Hidden figure test	87	Normal	Below average	Normal
iii) Sequencing ability test	411	Borderline	Impaired	Impaired
2. Constructional ability test
i) 2D construction	301	Normal	Below average	Impaired
ii) 3D construction	57	Normal	Normal	Normal
iii) Block printing	207	Normal	Below average	Below average
3. Sensory–motor ability
i) Tactile discrimination test
a) Dominant hand	218	Borderline	Impaired	Impaired
b) Nondominant hand	177	Borderline	Impaired	Impaired
ii) Dexterity test
a) Dominant hand	42	Normal	Impaired	Impaired
b) Nondominant hand	42	Normal	Impaired	Impaired
iii) Coordination test
a) Dominant hand	44	Normal	Normal	Normal
b) Nondominant hand	100	Normal	Normal	Normal
4. Ability to follow instruction
i) Written instruction test	690	Normal	Impaired	Borderline
ii) Visual instruction test	480	Normal	Normal	Normal
iii) Spoken instruction test	230	Borderline	Normal	Borderline

The upper and lower extremity functional scale measure activities with an affected limb are shown in Table 2.[3,4] His grip on the right hand was 20 kg, and his left hand showed 33 kg. The flexion of his right knee was up to 110 degrees compared with 105 degrees from the initial assessment. His wrist flexion and extension were 50 degrees compared with the initial assessment, which showed 45 and 15 degrees, respectively. The right ulnar and radial deviation was 25 and 30 degrees, respectively, compared with 15 and 20 degrees during the initial assessment. The range of movement on other joints of the limbs was within normal range. He managed to lift 50 lbs from waist-to-waist level and waist-to-floor level, while he was able to lift 33 lbs from waist-to-shoulder level. He was able to carry a load of 45 lbs covering 40 feet using both hands, and 35 lbs and 30 lbs were the carrying capacity of the left and right hands, respectively, covering the same distance. The pulling capacity was 20.6 lbs and 14.6 lbs for the left and right upper limbs, respectively, while 19.7 lbs and 19.0 lbs were the pushing capacity for the left and right upper limbs, respectively. He was able to stand continuously only for 19 minutes due to fatigue while performing functional activities but showed no difficulty in prolonged sitting. He managed to cover a distance of 2 km after a short break in 42 minutes and accomplished to climb 200 steps after a short break.

Table 2:

Upper and lower extremity functional scales

Extremity	2019	2020
Upper	60	68
Lower	43	51

DISCUSSION

Activities of daily living are affected among patients with cognitive and physical deficits and may have a negative influence on returning to work. The objectives of the study are to perform an assessment of cognitive and physical deficits to plan a rehabilitation program including on-job evaluation and returning the employee to his original work. The COTNAB is a standardized evaluation for neurological conditions among those having brain injury and stroke.[5] The upper and lower extremity functional scale measure activities were used to assess physical deficits. The COTNAB is also used as a therapeutic intervention in this patient by performing Logico Piccolo Grolier book exercises, geometric sticks, and graded pinch exercises with memory recall exercises, while various physical exercises were introduced to improve physical deficits.

In the rehabilitation center, COTNAB was used as a prognostic tool and therapeutic intervention where the patient had gone through various sessions to improve his constructional ability with sensory and motor functional areas using Logico Piccolo Grolier book exercises, geometric sticks, and graded pinch exercises with memory recall exercises was conducted. There are several advantages to using neurological scales such as COTNAB as they are a potent prognostic indicator, easily managed as they are straightforward, and are validated. The limitations include different instruments that should be used according to the requirement of patients and clinical management and at different stages of injuries for appropriate planning of rehabilitation. Moreover, different locales such as hospital or clinic may necessitate different tools to assess different stages of recovery. The tool should be validated for local language and specific injury or diseases before applying to the patients.[6] It may have limited value in mild and severe cases, and several slight deficits may have a comparable score to a few major deficits.

Functional capacity evaluation (FCE) is a medical assessment based on the performance of physical and cognitive capabilities of individuals to safely perform the job and other major life ventures.[7] The clinical measurements and observations are objectively assessed and may contemplate subjective assessment based on self-reported pain and disability through self-administered questionnaires. The pertinent tests are conducted according to the job demand and recognize the gap between the injured person's capabilities with the job demand. The maximum capacity of the evaluation was conducted in January 2020. The range of movement exercises including kneeling to bending knee, cycling, and leg press was introduced during physiotherapy sessions. Balance exercises and stair training were taught besides endurance, strengthening, and also mobility using a stepper and treadmill.

Ideally, a workplace assessment should be conducted to give clearer information on the job scope. The test conducted should be safe, consistent, and valid. During the evaluation, heart rate and blood pressure are measured to recognize the individual's effort level. The oxygen saturation, respiratory rate, and swelling are observed as other physiological assessments. During the evaluation, the balance and movement patterns are observed and recorded. The examiner also observes pain or fatigue exhibited by the individual while performing a task. The work simulation testing is done at the worksite if the equipment is not available to test the individual's capabilities.

The patient is currently noted to have slow memory recall and weakness of the right grip. He also complains of slow movement during a walk with a limited range of movement at the right wrist and right knee.

The patient is fit to be a clerk based on FCE and on-job assessment after going through various sessions to improve the cognition and function of extremities. FCE is precisely measured behavioral tests and should be inferred from the patient's personal and environmental setting though COTNAB may be of limited value in mild or severe cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.