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Rheumatology 2001; 40: 1201-1205
© 2001 British Society for Rheumatology
Editorial |
Keeping our patients at work: implications for the management of those with rheumatoid arthritis and musculoskeletal conditions
Northwick Park Hospital and Institute of Medical Research, Harrow HA1 3UJ and
1 Rheumatism and Rehabilitation Research Unit, 36 Clarendon Road, Leeds LS2 9NZ, UK
The enormous burden being placed on all societies by musculoskeletal conditions is only now coming to be recognized [1]. The musculoskeletal conditions are the commonest cause of disability and severe disability in the UK [2] and the biggest cause of chronic impairment in the USA [1]. Back pain and arthritis are the commonest causes of chronic pain in the community [3], and those with these conditions are among the hardest to help to return to work [4].
It can readily be appreciated that the impact of musculoskeletal disorders on the world's economy is very great. Indeed, governments have noted the exponential growth of Social Security Disability Insurance (SSDI) in the USA [5] and of incapacity benefits in the UK [6].
The recent report by the British Society of Rehabilitation Medicine (BSRM) has also noted the very large costs placed on the state by these conditions. The Department of Social Security figures for sickness absence from back pain alone has amounted to around 90 million days for each of the periods 1994/95, 1995/96, 1996/97 and 1997/98. These figures exclude the cost of managing long-term illness and disability and the loss of revenue from taxation [6].
Musculoskeletal problems are the commonest reason for receiving incapacity benefit in the UK. Many go on this but few leave: every week 3000 people go on to this benefit and a mere 300 ever return to work. In total, 2.8 million (8% of the 35 million workforce) receive state benefits on the grounds of medical incapacity to work at a cost of £7 billion per year [6].
The total cost of back pain alone corresponds to 1–2% of the gross national product (GNP) in several countries [7], and in The Netherlands neck pain has been estimated to cost about 0.1% of the GNP [8]. The musculoskeletal conditions (including those with arthritis and fractures) are estimated to cost 2.5% of the GNP in the USA [7].
The costs are not limited to those incurred by the state. Costs to the employer are substantial in terms of sick leave, lost production, recruitment and retraining, compensation, litigation and insurance, property damage (sometimes), medical treatment (sometimes) and early retirement. The costs to the individual are also heavy [9]. They include not only the reduction in income but also all that this implies in terms of diminished opportunities for the affected family.
The problem can be looked at from another viewpoint, that of work-related disorders, of which there were 2 million cases (self-reported) in the UK in 1995 [10]. Back, neck and limb disorders constituted almost 60% of these. The latest labour force survey, taken in the winter of 1998/99, identified over 6.4 million people with a current long-term disability or health problem, i.e. 18% of the working population [11].
The Health and Safety Executive (HSE) [10] estimated that there were 2 million self-reported work-related illnesses in Great Britain in 1995. Back, neck or limb problems represented almost 60% of all the work-related illness reported in this study. The HSE estimates that around 3.7 million working days are lost each year as a result of back pain alone (excluding back pain related to other musculoskeletal conditions), about 10 days being lost per employee with a back problem. Of course, some backache that occurs in the population of working age is not related to work factors.
The exact prevalence of work-related upper limb disorder is unclear, but the HSE, using self-reported data, estimates it as over 1% of the work force (including ex-workers), certain occupational groups having a high prevalence [10].
Many rheumatologists, familiar with these facts, use a checklist for those who may have these conditions. Thus, awkward postures, high static muscle load, high force exertion on the hands, sudden application of force, work with short cycle times, little variety of tasks, frequent tight deadlines, inadequate rest or recovery periods, high cognitive demands, little control over work, a cold work environment, vibration and localized mechanical stresses on tissues constitute a wide range of causative or contributing factors [12], and this suggests that an equally diverse range of remedies is needed. The UK Access to Work scheme represents a way into many useful responses. Seating, easels and ergonomic keyboards may all be usefully provided under these programmes [13] and clear explanations of these schemes are given by Arthritis Care [14].
A large part of a rheumatologist's workload is accounted for by inflammatory arthritis, the model for which is rheumatoid arthritis. The variable course, pain, varying disability and morning stiffness are particularly difficult to accommodate to the demands of the workplace. The prevalence of work disability in this disease is high [15–19] and much job loss occurs in the first year [17], often before the patient is referred to hospital or started on disease-modifying anti-rheumatic drugs [13, 16]. The many common factors influencing work disability in rheumatoid arthritis include [16]:
- employment factors, e.g. the nature of the job, the physical activity needed, the degree of autonomy at work [20], the work environment [17] and transport to work;
- employee factors, e.g. age at onset of rheumatoid arthritis, marital status, education [21] and motivation for work;
- disease factors, e.g. time since onset, level of disability and symptoms affecting disability [early morning stiffness, loss of limb function, recurrent flare-ups (which make individuals feel unreliable) and general debility] [17, 20];
- other factors, predominant among which are those relating to the time taken for health care, e.g. visits to the general practitioner or hospital and in-patient care for surgery or rehabilitation.
In rheumatoid arthritis, high levels of pain, disability or both are high risk factors for experiencing high levels of mental distress [22].
Work loss in rheumatoid arthritis relates to the physical nature of work [19], control over the pace of work [19] and remaining in the job that was held when the diagnosis was made [19]. Return to work relates to education [23], geography [23] and work history [23]. Although many patients stop work totally, a small proportion may change jobs or restrict their hours of work [16, 17]. Others, particularly those with fatigue, may do demanding tasks early in the day and easier tasks at the end of the day [20]. Social and work factors combined have a far larger effect on work disability than disease factors [15]. There is a strong likelihood that pain and depression can be aggravated by work disability even when controlling for disease activity [21].
The lifetime costs of rheumatoid arthritis were estimated by Stone many years ago [24]. They included medical care expenses and the costs of work loss. More recently, the direct costs were quantified by van Jaarsveld et al. [25] in The Netherlands. The average annual direct cost per patient was £3680 (however, the overall cost for a lifetime at the 1977 level was $20 412 per person [24], almost certainly an underestimate and from a time when fewer women were working). In this context, it is worth recognizing that patients with arthritis may be well qualified but may nevertheless be less well represented in the labour force than their able-bodied peers [26]. It is known that, whilst 85% of non-disabled persons are economically active, only 51% of those declaring a disability are employed [11].
All these features mean that the costs to state, employer and worker are large. Effective, early intervention is of the greatest importance.
The management of rheumatoid arthritis has become more effective and more holistic in the last decade or so. Clinicians have access to powerful, if sometimes expensive, treatments. Well-organized departments are led by physicians, but team-working is the rule. These teams include nurse specialists, occupational therapists and physiotherapists. They recognize that all work in partnership with patients [27]. They employ self-management techniques not only for pain [28] but also for lifestyle matters [29]. They are thus in an excellent position to use vocational rehabilitation maximally. Yet the evidence is that in the UK they probably do not. This may be explained in part—but only in part—by the withdrawal of vocational rehabilitation from the NHS in the last 20 yr. In consequence, some younger rheumatologists may be unfamiliar with the concept.
The recent report by the BSRM (‘Vocational rehabilitation: the way forward’) [6] deals with vocational rehabilitation, almost a lost skill in the NHS, and seeks to bring it back to the centre stage. It provides a wealth of useful evidence for the interested rheumatology team. The BSRM defined vocational rehabilitation as ‘a process whereby those disadvantaged by illness or disability can be enabled to access, maintain or return to employment, or other useful occupation’. Key features of it are:
- recognition that the best way to maintain work is to communicate quickly with the employer at disease onset or at a flare-up [5];
- encouragement of openness between patient and employer [14];
- recognition that the current employer is more likely to facilitate continued working than a new employer.
‘Vocational rehabilitation has the ability to prevent or minimize potentially devastating personal consequences that often accompany loss of employment’ [4]. It also reduces dependence on other persons and agencies and saves money for the taxpayer and third parties. Research has shown that vocational rehabilitation schemes have the potential to produce a return on costs of between 2- and 10-fold [6]. Economic benefits can be measured in terms of reduced sickness absence, reduced early retirement, increased productivity, continued payment of taxes and reduced payment of state benefits [6].
Many examples of such innovations exist, both in government schemes, including the Access to Work programmes [4, 6, 13, 14, 23, 30] and those devised by voluntary organisations, such as those by MIND and the Royal National Institute for the Blind [31]. Local councils and regional development agencies may give start-up grants and business advisers may be found through Training and Enterprise Councils.
Legislation is of the greatest importance. The Americans with Disabilities Act has been influential; the UK's Disability Discrimination Act still has to be evaluated and tested by case law. Such legislation places emphasis on the removal of physical and other barriers as a means of promoting participation in society for those with disabilities.
What we hope to do is to turn adversity to advantage, or ‘To turn what is classed as my disability into a vital ability for my future career’ [32].
The objective of much investment and many innovations has been to get people back to work after long periods of unemployment/sickness. Whilst this is a laudable aim, evidence is accumulating that it is better for the individual worker and the employer to work in a preventative mode.
Those who are likely to have difficulties in their job should be referred to vocational rehabilitation agencies before they are in receipt of state benefits [4]. Emphasis has to be placed on speedy action to keep people in employment. Given the difficulty in returning to employment after incapacity benefit is awarded and knowing that there is only a 50% chance of a person retaining his or her work after 6 months of sickness absence from back pain [6], legislation and benefits must be so structured as to encourage the worker and employer to seek rehabilitation and vocational rehabilitation at an early stage [33]. We can learn something from the Dutch system [34]. In this, the grading of employment disability is fine enough to allow a graduated return, because the financial disincentive of the all-or-none benefits system of the UK is absent. At the same time, the workplace has been adapted and made ready.
But an additional factor is required: a health service ready to respond to the worker's urgent need. The preliminary evidence from organizations representing those with disabilities, contacted by the BSRM in the preparation of their report, was clear; there was a widespread perception that the process of referral to a consultant, investigation and rehabilitation was too slow to prevent job loss. The rehabilitation on offer also lacks focus on urgent work-related problems: the reports from the TUC [35] and the Association of British Insurers (in its second study of bodily injury awards) [36] expressed the opinion that the NHS was not responding adequately to these needs. Some voluntary organizations felt the NHS was not aware of workplace needs [6].
The paper by Gilworth et al. [13] in this issue of Rheumatology, whilst only a pilot study, also suggests that facts about work are not always elicited or may not contribute to the decision-making process in rheumatology clinics. Yet it may be that early aggressive treatment, which is known to reduce joint damage, may also increase job retention. This group is also looking at the production of a measure that will indicate the risk of job loss in rheumatoid arthritis. In addition, the local rheumatology service is incorporating relevant data into its longitudinal studies.
All rheumatologists now need to incorporate vocational rehabilitation assessments into their service. ‘To help correct this critical and expensive problem, the physician's challenge becomes the earliest possible identification of persons with work disability to vocational rehabilitation agencies’ [4]. Vocational rehabilitation is often initiated too late [13, 17].
Clinical staff, as we have said, are often ignorant of difficulties within the workplace and the ways in which the situation can be ameliorated. Only a small number of those needing vocational rehabilitation receive it, and in the UK too few visit the disability employment adviser at the job centre to access these services [13, 17].
Rheumatological assessments should take account of previous education, employment and health history, a physical and mental assessment of current work tasks (including ergonomics and stress), the investment of employers (e.g. knowledge and training) and the motivation of the employee for continuing employment or possibly retirement [4, 13, 37, 38]. Advice for employers, who may be uncertain how to arrange an employment assessment, is provided by RADAR (the Royal Association for Disability and Rehabilitation) and The Employers Forum on Disability.
Job modification is often the first defence for a job [13, 19, 20, 23, 30]. It may require minor adjustment to the workplace (e.g. to a computer), avoiding heavy manual tasks and occasionally obtaining assistance from other employees [20]. External barriers, such as stairs and toilets [20], may need modification and government assistance may be available for this purpose [6].
Sometimes it is impossible to return to the same job, even with modifications. Vocational education [4, 14, 30] or retraining [6, 14, 19, 30] is often provided by government schemes to facilitate returning to different work. Retraining may be given at the work site. Usually the Department of Employment will facilitate finding appropriate work [14]. The use of ‘therapeutic earnings’ can facilitate a way back into work for those who have lost work [14].
Intensive rehabilitation has been shown to get people off ‘welfare into work’ [23]. The rates of return to work were related to education, geography and work history.
Transport can be a major determinant of whether someone can return to work [17, 20, 30]. Schemes such as preferential parking, disabled stickers and special transport can make the difference between whether or not the patient continues to work. The Access to Work Scheme can provide a grant towards the extra travel costs necessitated through a disability [6, 14].
Self-employment [14] may be a way of maintaining an income for some individuals. Advantages include working from home and reducing transport. Work in the information technology fields may be appropriate. Advice is available from both the State and the voluntary sector [37], e.g. Disabled Living Centres and the Leonard Cheshire Workability Project [14]. The Prince's Youth Business Trust helps people aged 18–30 in setting up a business [14]. Self-employment has been shown to be advantageous in terms of continuing in work [15], autonomy at work [15, 16, 20, 39] and giving control over the pace and activities of work.
Arthritis Care (UK) [14] has been active in giving advice in this field, and local disability groups can also offer much assistance. Members of Young Arthritis Care have taken on mentoring—‘a structured and formalized process where the mentor takes on a directive and guidance role whereas counselling assumes a more reflective, non-directive format’ [32]. Mentoring may be particularly helpful if there are major emotional components in the disability. Arthritis Care also gives advice, in its leaflet ‘Working horizons’, on such practical tasks as writing CVs and job application forms [14], and provides a telephone helpline [14].
Many large employers have good human resource departments and occupational health schemes and these methods of helping employees are well accepted. Recent trends in the workplace, however, have included downsizing [40], which may have adverse effects on health and on the employment of disabled workers. Small employers may not have their own human resource department and may need advice and a reminder of their obligations under the Disability Discrimination Act [6].
Liaison between health workers and employers [37] should encourage a discussion between employee and line manager or supervisor, particularly if no occupational health or union advice is available. This helps to identify problems and promote action. Sometimes this will require arranging a vocational assessment from an outside body to assess the potential for job modification, change of duties or finding an alternative job, or for retraining or retirement.
Currently, this liaison rarely happens. Indeed, it may no longer be in the contract of therapists who might undertake vocational rehabilitation (or work preparatory to full vocational rehabilitation). The action and knowledge of line managers can be important for employees in difficulty [6] but currently few therapists are able to meet with them. Structured maintenance of contact with the employee during absence is important but often lacking [5].
There is room for many innovations: a novel approach to facilitating retention in work, that of disability leave, has been proposed recently [37] and may be appropriate when an individual first develops rheumatoid arthritis, before the longer-term implications have become clear.
The physician's role must be to have a high level of suspicion and to identify potential work disability early. Having done this, a more formal assessment may be done by a therapist in the team or by a nurse practitioner. Many interventions may be possible at the levels of disease or disability management, in providing rehabilitation of sufficient intensity or by advice within the workplace. Advice may be given on job modification, retraining and/or re-employment in the face of difficulties at work. Physicians can also share their knowledge of inflammatory arthritis and its prognosis with the patient and others involved in their return to work [15].
Physicians cannot be expected to give detailed advice on job modification, but if they were to know something of the value of vocational rehabilitation and how it is accessed, this would have a considerable impact [6, 13, 17]. Formal education for the physician in disability evaluation is rare both during and after the residency in the USA [38], and the disabling aspects of rheumatology are also neglected in the UK [41, 42]. The first requisite is that such training gains a high profile, so that the rheumatologist becomes a powerful advocate for the individual patient in the job situation and the rheumatology societies use their considerable influence to bring about change.
There are many changes in practice that might be implemented. One suggestion has been that every district should have a highly trained therapist specializing in vocational rehabilitation with a brief to cross agency boundaries and work outside the hospital [6]; many believe rehabilitation should take place in the workplace. The reintroduction of an evening clinic might be useful. Readers will know of other practices that would help their patients. But which will be most effective? We look forward to a lively debate!
Helpful addresses
Arthritis Care
Stephenson Way, London NW1 2HD, UK. Helpline 020 7380 6555 (Monday to Friday 10 am to 4 pm); Freephone 080 8800 4050.
The Employers Forum on Disability
Nutmeg House, Gainsford Street, London SE1 2NY, UK. Tel: 020 7403 3020.
RADAR
City Forum, City Road, London EC1V 8AF, UK. Many other addresses are given in [14].
Notes
Correspondence to: A. O. Frank. 
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