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Rheumatology 2001; 40: 1206-1210
© 2001 British Society for Rheumatology

Original Papers

Do rheumatologists recognize their patients' work-related problems?

G. Gilworth, R. Haigh, A. Tennant, M. A. Chamberlain and A. R. Harvey1

Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds and
1 Pinderfields and Pontefract NHS Trust, Pontefract General Infirmary, UK


   Abstract
Top
 Abstract
Introduction
 Management of rheumatoid...
 Aim of the study
 Method
 Results
 Discussion
 Appendix
 References
 
Objective. The question addressed in this pilot study was ‘Does the addition of an occupational health physiotherapist offering early vocational assessment influence the management of rheumatology patients (clinically and related to the workplace)?’

Method. Sequential vocational assessments were offered to 78 subjects with rheumatological complaints of more than 1 yr duration experiencing difficulties in working. The findings from the vocational assessments were fed back to rheumatologists. Where necessary and acceptable, workplace interventions were made and the Employment Service's Access to Work scheme was utilized to address the employment problems found.

Results. The intervention vocational assessments trebled the number of subjects seeing a Disability Employment Adviser (17% before the study, a further 37% during it). High levels of satisfaction were reported for interventions made at work. Some important changes to the management of some patients by a few doctors were made, but information from the vocational assessments did not reach them reliably in a number of cases.

Conclusion. An unmet need for advice and workplace aids and equipment was identified. Vocational assessment by a practitioner with clinical knowledge, ergonomic and workplace experience proved helpful to patients in this pilot study. Without vocational assessment, the hospital-based team rarely identified what were often remediable, work problems and appeared unaware of the appropriate referral route for this group of patients. Rheumatologists may need to expand their management to include consideration of work issues to ensure that their patients are referred early for appropriate ergonomic intervention when required. Further study is required to help facilitate easy identification in the clinical setting of patients with problems at work.

KEY WORDS: Rheumatology, Vocational assessment, Work disability, Job retention.


   Introduction
Top
 Abstract
 Introduction
Management of rheumatoid...
 Aim of the study
 Method
 Results
 Discussion
 Appendix
 References
 
Paid work enhances well-being and health [1]. The absence of work tends to induce the opposite feelings and has been shown to increase reported levels of pain and depression in patients work disabled with rheumatoid arthritis (RA) [2].

Work disability has been defined as the inability to perform work [3]. It is a term used frequently in the American literature [2, 4, 5], with the implication that the cessation of employment is because of an individual's disability or health problem. It has been widely reported that musculoskeletal diseases and arthritis are the leading cause of work disability [3, 6, 7].

Work disability is a common outcome in RA with a prevalence of between 37 and 85% [5, 8, 9]. Many patients lose their jobs soon after diagnosis. A recent UK study found that almost 15% of patients had lost their jobs within the first 12 months following onset, with a further 16% loosing their jobs within the next 29 months [10].

There is less evidence about the impact of osteoarthritis (OA) on work, perhaps because it has no systematic component and is a significant health problem of older people [11]. Nevertheless, Gabriel et al. [12] demonstrated that subjects with OA were more likely to reduce their work hours or be unable to secure employment because of illness, compared with a non-arthritis control group.

Several important risk factors have been identified as predictors of work disability in RA, although the relative importance of these factors remains unclear. The nature of the work, particularly physical demands at work, presenting level of disability [initial Health Assessment Questionnaire scores] [13], and geographical factors [14, 15] have been shown to have negative effects on job retention. In contrast, educational attainments [16], autonomy within the workplace, self-employment [17] and the subjects’ levels of motivation and determination to work, despite significant disease [14] have all been reported as important predictors of continued employment.


   Management of rheumatoid conditions
Top
 Abstract
 Introduction
 Management of rheumatoid...
Aim of the study
 Method
 Results
 Discussion
 Appendix
 References
 
A recent report focusing on the clinical management of both RA and OA emphasizes the importance of the multidisciplinary team, continuity and seamless care between primary and secondary services [11]. It has been suggested that the clinical treatment of rheumatic disorders is aimed primarily at pain relief and minimizing joint impairment, rather than addressing the need to retain the patient in employment [18]. Yet bearing in mind the effects of unemployment and low income on quality of life, it was our contention that one of the aims of management of rheumatological patients must be to address any work retention issues. The importance of job retention for people with health problems and disabilities and the difficulty of returning people to paid employment once they start claiming incapacity benefit has recently been documented in a report focused on vocational rehabilitation [19].


   Aim of the study
Top
 Abstract
 Introduction
 Management of rheumatoid...
 Aim of the study
Method
 Results
 Discussion
 Appendix
 References
 
The aim of this study was to identify individuals having difficulty at work at an early stage and insert into the clinical team an occupational health physiotherapist trained in vocational assessment and document whether this has any effect either on the workplace management of these individuals or the clinician's practice.


   Method
Top
 Abstract
 Introduction
 Management of rheumatoid...
 Aim of the study
 Method
Results
 Discussion
 Appendix
 References
 
Recruitment
The subjects for the study were recruited from rheumatology clinics in Leeds, Huddersfield and Pontefract, UK.

The inclusion criteria were:

  • • in paid work, including part-time work and self-employment. Patients off sick (not more than 6 months) but intending to return to work were included;
  • • attending a rheumatology clinic (all diagnoses were accepted);
  • • the rheumatological condition needed to be longstanding (duration of symptoms of at least 1 yr). There were two reasons for this: (1) this would automatically ensure subjects were eligible for the Employment Service Access to Work scheme; (2) individuals with a self-limiting condition would not be able to follow through for the duration of the study;
  • • a score above the agreed threshold in the recruitment questionnaire (see below).

Patients were excluded when:

  • • over 60 yr of age;
  • • not in paid work, or off sick and not intending to return to work.

Recruitment into the study was via a short (seven-item) self-administered questionnaire (see Appendix), designed to select patients experiencing a mismatch between the demands of their job and their physical capabilities. The completed questionnaire had a possible score of between 0 and 19, a score of 6 or above being considered to indicate levels of mismatch or potential difficulties at work high enough to be included in the study. Informed consent to participate in the study was then obtained from the patient by the rheumatologist.

The vocational assessment
To strengthen hospital and Employment Service links, the assessments were held at the Employment Service, Regional Disability Service in Leeds and were completed by an occupational health physiotherapist. No standardized vocational assessment protocol was available, so one was developed building on standard practice of an experienced occupational health physiotherapist working in the field. The vocational assessment included details of employer, work tasks, work postures and a range of questions to establish the extent of any mismatch between the demands of the work tasks and the subject's functional abilities. A workplace visit was offered to all subjects. Subsequently, the findings from the vocational assessment were sent in a short report to the hospital doctor to be read at the next clinic. Sequential vocational assessments were carried out by the physiotherapist at 6–12-month intervals. Each subject was offered either three or four assessments depending on whether they were recruited early or later on in the study period. On subsequent vocational assessments, satisfaction levels were recorded for any intervention the patient had received since the previous assessment.

Clinic reports
The vocational assessment report was sent to the rheumatologist in a sealed envelope. Once the doctor had completed an initial assessment and treatment plan, the report from the vocational assessment was to be read. Any subsequent changes in clinical management were recorded on a second treatment plan. Previous successful use of this study design had been reported from a project evaluating the contribution of the Stanford HAQ in rheumatology clinics [20].

Exit survey
An exit questionnaire was used to gather information about the experiences of the study participants. The exit questionnaire also gave an indication of the outcome for clients who had received advice and/or equipment to help them cope more effectively at work.


   Results
Top
 Abstract
 Introduction
 Management of rheumatoid...
 Aim of the study
 Method
 Results
Discussion
 Appendix
 References
 
Attendance and health status
One hundred and fourteen subjects who agreed to participate in the study were recruited in the rheumatology clinics, but only 78 attended for the full assessment with the physiotherapist. Analysis of these two groups showed no significant differences between those attending (n=78) and those who failed to attend (n=35) by age, gender or diagnosis (RA vs Other). All 78 subjects were employed at entry to the study and had an age range of 22–60 yr (mean 40.4). Twenty-nine (37%) had RA. The other two largest diagnostic groups were upper limb pain (including shoulder capsulitis) (n=18, 23%) and low back pain (n=7, 9%). Fifty-five (71%) were female.

Contact with other services, e.g. therapy services and the Employment Service
At entry to the study, the majority of the subjects (n=59, 76%) were receiving physiotherapy treatment or had seen a physiotherapist within the last 6 months. A large portion had also been referred for occupational therapy and/or appliances (see Table 1Go). However, prior to the study, only 13 (17%) of the subjects had seen a Disability Employment Adviser (DEA). There were no significant differences between those who had seen a DEA and those who had not, by age, gender or diagnosis or on any of the items on the recruitment questionnaire (P>0.01) at baseline. During the study, a further 29 (37%) were referred to a DEA by the occupational health physiotherapist, often receiving practical support under the Access to Work Scheme enabling them to cope better at work.


View this table:
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  		TABLE 1. Number of subjects who had been referred to other services within the previous 6 months at entry to the study

 
Patient satisfaction with equipment provided in the whole workplace was measured on a scale of 1–7 using visual representation of facial expressions. Seven was the best score, represented by a very happy face. Ninety-six per cent of responses regarding satisfaction with equipment provided were scores of 5 or above. Intervention in the workplace included advice on work organization and alternative duties with the same employer. Provision of equipment was individually tailored to patient's needs. The most common change was provision of better seating (n=19), ‘ergonomic’ (split) keyboards and desk top slopes.

Impact on clinical decision-making
In total, 166 sealed clinic reports were sent, but data were only available for 60. Analysis of the reports that arrived (n=60) against those ‘lost’ (n=106) showed no significant differences in the gender of the study subjects, although there were statistically significant differences in age (P<0.05) and diagnosis (P<0.05). Envelopes that arrived were more likely to relate to older RA patients than younger ‘other’ patients.

Effecting change in clinical management was rare, but nevertheless potentially important. Of 60 treatment plans completed, nine (15%) showed a change in treatment. Some potentially important decisions were aided by the information in the reports, e.g. confirmation to start a patient on a second-line drug therapy and replacement of working splints for one subject. The most common change was referral for physiotherapy treatment (n=3).

Results of the exit questionnaire
Of the 78 patients attending for vocational assessment, 55 (71%) returned the questionnaire. {chi}2 analysis revealed that patients who attended three or four vocational assessments were significantly more likely to return the exit questionnaire than those who attended one or two vocational assessments ({chi}=5.674, P<0.05).

Forty of the 55 respondents (73%) remained in paid employment at the end of the study. Neither the provision of equipment nor advice appeared to make a significant difference to whether subjects were retained in work over the timescale of the project (3 yr). However, of the 31 respondents who received equipment or had adaptations provided under the Access to Work Scheme, 30 (91%) reported that this helped how they coped at work.


   Discussion
Top
 Abstract
 Introduction
 Management of rheumatoid...
 Aim of the study
 Method
 Results
 Discussion
Appendix
 References
 
The importance of work to both individuals and society is widely acknowledged. Despite advances in the drugs available to treat rheumatic diseases, they remain a major cause of job loss [6, 8, 10]. Once individuals have lost their customary work and are claiming incapacity benefits, it has been reported to be much more difficult for them to return to the workforce [19].

There is evidence that loss of work occurs very early in RA and there is increasing evidence of the difficulties faced by patients with other rheumatological conditions who wish to remain in work [10, 21, 22]. Consequently, intervention and awareness of job retention issues need to occur very early after diagnosis.

In this pilot study, we aimed to assess the impact made by the addition of an occupational health physiotherapist to the clinical team. Of the 78 subjects who participated by having vocational assessment, 29 (37%) were helped by intervention from a DEA following referral by this physiotherapist. None of these had been recognized as needing such intervention in the clinic. A large proportion had received physiotherapy treatment and or occupational therapy but had not been referred for specific workplace intervention by any of the hospital-based team.

It is acknowledged there were shortcomings in the feedback loop providing information from vocational assessments to the rheumatologists in clinic; this was largely due to changes in clinic practice and staff. In the small number of cases where reports did get through (n=60), the vocational assessments were shown to have the capacity to change clinical practice in one in six subjects (n=9, 15%).

Probably the most important finding is that the rheumatologists and hospital-based therapists did not appear to recognize which of their patients could benefit from referral to a DEA and the subsequent support that could be offered to the patients in the workplace. An alternative explanation is that they may have recognized the problem but were unclear what they should do with this information. Why should this be? Links between the Health Service and the Employment Service are poor. It is probable that none of the hospital-based team would have met the local DEAs, and likely that if they have referred patients in the past they would not have received feedback. Currently virtually no therapists have job descriptions including regular liaison with Employment Service staff.

To achieve joined up working the situation needs interaction between Health Service and Employment Service Disability Service Teams. How might this be achieved? Appointment of a liaison therapist to the clinical team, with a job description to enable them to cross agency boundaries, would allow links to be developed between the hospital-based team and the local Employment Service Disability Service Teams to provide a coherent care pathway to address job retention issues.

This preliminary work has identified the issue of recognition of work instability (this may be defined as the consequences of a mismatch between an individual's functional capacity and their job demands) by the clinical team. If those individuals requiring support in the workplace could be identified by a simple screening tool this could facilitate appropriate, timely referral to the DEA. Currently there is no validated measurement tool available which focuses specifically on the identification of those individuals having difficulties at work. Ongoing work will focus on the development of a work instability scale.


   Appendix
Top
 Abstract
 Introduction
 Management of rheumatoid...
 Aim of the study
 Method
 Results
 Discussion
 Appendix
References
 
Recruitment questionnaire

Not at all Rarely Some of the Most of the
time time
1. Does your condition affect the rate at
which you are able to carry out any of
your tasks at work?
2. Does your condition affect the amount of
work you are able to complete in a set
time or in a normal working day, e.g. do
you find you need longer or more
frequent rests?
3. Does your condition prevent you from
doing certain aspects of your job or make
parts of your job difficult?
4. Does your condition affect the standard
of your work, i.e. is it harder to
consistently produce the same quality of work?
0 1 2 3


5. Over the last year has your arthritis/condition necessitated any changes *Yes/No
or adaptations to your working methods and/or equipment used? 2 0

This section of the questionnaire is to give us information about if your condition affects your work attendance

6. How much of your sickness absence is a result of your arthritis/condition?


(tick 1 column)
None Less than half More than half All
0 1 2 3


7. Are most of your sickness absences certified by a doctor, i.e. over 7 days off? *Yes/No
2 0

*Please delete as required

Thank you for completing this questionnaire


   Acknowledgments
 
We thank all the patients and staff who helped during the project, in particular M. Lazenby, medical secretary at Leeds General Infirmary. The authors would like to thank the Arthritis Research Campaign (UK) for their financial support of the project. This study was also supported by the Employment Service.


   Notes
 
Correspondence to: G. Gilworth, Rheumatology and Rehabilitation Research Unit, University of Leeds, 36 Clarendon Road, Leeds LS2 9NZ, UK. Back


   References
Top
 Abstract
 Introduction
 Management of rheumatoid...
 Aim of the study
 Method
 Results
 Discussion
 Appendix
 References
 

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Submitted 16 March 2001; Accepted 12 April 2001


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A. O. Frank and M. A. Chamberlain
Keeping our patients at work: implications for the management of those with rheumatoid arthritis and musculoskeletal conditions
Rheumatology, November 1, 2001; 40(11): 1201 - 1205.
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