Economic impact of musculoskeletal disorders (MSDs) on work in Europe




Abstract


Musculoskeletal disorders (MSDs) are the leading cause of work disability, sickness absence from work, ‘presenteeism’ and loss of productivity across all the European Union (EU) member states. It is estimated that the total cost of lost productivity attributable to MSDs among people of working age in the EU could be as high as 2% of gross domestic product (GDP). This paper examines the available evidence on the economic burden of MSDs on work across Europe and highlights areas of policy, clinical and employment practice which might improve work outcomes for individuals and families and reduce the economic and social costs of MSDs.


This paper sets out what we know about the economic and productivity impact of MSDs on people of working age in Europe and describes the challenges faced by both current and future European workers, their families and carers, their employers and, ultimately, state agencies. It also looks at the economic case for early, work-focussed interventions that promote job retention and vocational rehabilitation and reduce productivity losses.


Context


There are four contextual factors, which frame the issue of workforce health in most European Union (EU) member states.


The first is the ‘ageing workforce’. Across the EU, the proportion of workers aged 50 years or more is 2 times that of those aged 25 years or younger. This is a disparity which is expected to worsen for several decades to come. With ageing comes a greater risk of poor health and premature withdrawal from the labour market. In some developed economies, almost half of those aged between 45 and 65 years, who are no longer in the workforce, have become economically inactive as a result of poor health .


Second, with a ‘pension crisis’ in most member states (difficulty in paying for pensions due to a difference between pension obligations and resources set aside to fund them), we know that a higher proportion of older workers will need to work longer than they do today and, increasingly, beyond the default retirement age. Policy-makers know that, with dependency ratios (the number of economically active people supporting the economically inactive) becoming more stretched, this trend needs to be mitigated.


Third, the ‘growing burden of chronic disease’ in the EU population will mean that (with an ageing workforce increasingly having to retire later) the productive capacity of the workforce risks is being compromised by ill health. Each year cardiovascular disease (CVD) causes over 4 million deaths in Europe and over 1.9 million deaths in the EU. CVD causes 47% of all deaths in Europe and 40% in the EU. In 2009, production losses due to mortality and morbidity associated with CVD cost the EU almost €46 billion, with 59% of this cost due to death (€27 billion) and 41% due to illness (€19 billion) in those of working age . Almost 700,000 EU citizens die from smoking-related illnesses in Europe each year (and around 50% of smokers die prematurely – on average 14 years earlier) . Forecasts tell us that the proportion of EU workers with long-term chronic conditions is on the rise; by 2030 over 20 million UK workers will have a long-term condition . Chronic diseases with low mortality, but high morbidity, impact on the individuals’ ability to participate in the labour market. For example, 100 million European citizens suffer from chronic musculoskeletal pain and musculoskeletal disorders (MSDs) , including 40 million workers who attribute their MSD directly to their work .


Fourth, ‘widening health inequalities’ in many EU member states remain a significant burden. As Marmot et al. have pointed out, work is a ‘social determinant’ of health and these labour market inequalities can ‘spill over’ into wider public health outcomes, especially if access to good-quality jobs is limited or unequally distributed.


Economic growth and social inclusion both rely on the ability of individuals of working age to remain connected to the labour market, to develop and contribute their skills and to sustain high levels of work productivity. In this context, it is important that individuals remain healthy and active . As the European Commission’s Health Strategy argues:


‘Health is important for the wellbeing of individuals and society, but a healthy population is also a prerequisite for econom ic productivity and prosperity.’


In the current economic environment, these factors still impede progress towards the achievement of the goal of a healthy and productive working-age population. Some of the solutions lie in the erosion of rigidities in some EU labour markets, some have their origins in declining public health, others focus on the behaviour of individuals and employers and some others focus on the way that health care priorities are set.


The consequences of poor workforce health are wide-ranging, resulting in a large and varied burden of costs. Chronic ill health means that many workers are not available to work or are not working productively on a daily basis. According to the latest European Working Conditions Survey (EWCS) (Parent-Thirion et al.) , 35.6% of European workers missed between 1 and 15 days of work due to ill health in 2010, with further 7.5% staying away from work for more than 15 days . In addition, even when individuals are at work, they may not be performing to their full capacity. EWCS reports that 39.2% of Europeans went to work despite being unwell enough to take sickness absence (so-called ‘presenteeism’). Reduced work productivity associated with mental health-related presenteeism has been estimated to cost employers about 1.5 times more than sickness absence .


Having a significant proportion of the Europe’s working-age population unable to work through ill health – even in a favourable economic climate – can reduce the aggregate level of labour productivity in an economy and can damage the competitiveness and effectiveness of European businesses.


In addition to the losses in the labour market, European health care and welfare systems are facing an increasing burden from supporting individuals with chronic disease who are out of work. We know that early onset of chronic conditions, coupled with unemployment and job loss, has serious financial and health consequences for individuals . Australian data among 45–65-year-olds show that, collectively, those leaving work prematurely owing to ill health lost up to U$18 billion in income each year, thereby increasing the risk of falling into poverty and social exclusion . Studies have also shown widespread deterioration in aspects of physical and mental well-being amongst those who lose their jobs, which can persist for many months .


Another area of concern, if people leave the labour market prematurely owing to ill health, is the impact on their families and carers. Not only does informal care for those with long-term, chronic, or fluctuating health conditions incur intangible costs, it is often the case that the working lives and productivity of family members with caring responsibilities are disrupted and compromised . This compounds the impact of premature labour market exit.


In this paper, we focus specifically on musculoskeletal disorders (MSDs) in the EU working-age population. The Global Burden of Disease data show that back pain accounts for the highest proportion of years lost to disability (YLDs) of all conditions, with neck pain and other MSDs all in the top 10 ranking. MSDs affect at least 100 million people in Europe, accounting for half of all European absences from work and for 60% of permanent work incapacity. In some EU countries, MSDs account for 40% of the cost of worker compensation, leading to a reduction of 1–2% in the gross domestic product (GDP) of individual member states. There is also a link between MSDs and mental health , and there is growing evidence that the ‘co-morbidity’ of these two conditions is a significant factor inhibiting early return to work (RTW). Individuals with MSDs are also likely to have depression or anxiety problems related to their conditions .


Against this background, this paper examines some of these issues and highlights why better coordinated efforts to improve the musculoskeletal health of the EU workforce are essential if we are to achieve the goals for economic prosperity and social inclusion, to which both the European Commission and national governments aspire.




The prevalence of MSDs and their impact on work


In an ad hoc analysis of the European Labour Force Survey commissioned by DG Employment and Social Affairs in Brussels , MSDs accounted for 53% of all work-related diseases in the EU-15. Work-related MSDs resulted in most lost days and permanent incapacity to work. Overall, they accounted for 50% of all absences from work lasting for more than three days, 49% of all absences lasting two weeks or more and about 60% of all reported cases of permanent incapacity. The analysis estimated that the total costs of work-related MSDs were in the region of €240 billion or up to 2% of GDP. MSDs are, according to this analysis, responsible for 40–50% of the costs of all work-related health issues.


The impact of MSDs on the individual and their ability to work varies significantly from person to person. As a result, attempts to measure the extent of work disability differ according to the methods of data collection being used, respondent selection, sick pay regulations and definitions of work disability. Work disability usually refers to cessation of employment, reduced working hours or claiming of disability benefits.


MSDs can cause work-limiting pain and fatigue which many people feel unable to disclose. One study suggests that chronic musculoskeletal pain (CMP) remains undiagnosed in 42% of adult cases . Despite this, 67% reported that pain caused a significant reduction in their quality of life, 49% were limited in the kind of work they were able to perform and 25% of adults with CMP have never consulted a doctor with regard to their pain. Other research shows that up to 30% of workers with conditions such as rheumatoid arthritis (RA) are reluctant to disclose their condition to their colleagues and managers because they fear discrimination . The stigma associated with non-disclosure may also lead to increased mental distress as well as ‘presenteeism’ – the tendency of workers to go to work when they are ill enough to stay at home.


In the following sections, we will study the workability impact of three distinct MSDs – work-related upper limb disorders (WRULDs), back pain and RA.




The prevalence of MSDs and their impact on work


In an ad hoc analysis of the European Labour Force Survey commissioned by DG Employment and Social Affairs in Brussels , MSDs accounted for 53% of all work-related diseases in the EU-15. Work-related MSDs resulted in most lost days and permanent incapacity to work. Overall, they accounted for 50% of all absences from work lasting for more than three days, 49% of all absences lasting two weeks or more and about 60% of all reported cases of permanent incapacity. The analysis estimated that the total costs of work-related MSDs were in the region of €240 billion or up to 2% of GDP. MSDs are, according to this analysis, responsible for 40–50% of the costs of all work-related health issues.


The impact of MSDs on the individual and their ability to work varies significantly from person to person. As a result, attempts to measure the extent of work disability differ according to the methods of data collection being used, respondent selection, sick pay regulations and definitions of work disability. Work disability usually refers to cessation of employment, reduced working hours or claiming of disability benefits.


MSDs can cause work-limiting pain and fatigue which many people feel unable to disclose. One study suggests that chronic musculoskeletal pain (CMP) remains undiagnosed in 42% of adult cases . Despite this, 67% reported that pain caused a significant reduction in their quality of life, 49% were limited in the kind of work they were able to perform and 25% of adults with CMP have never consulted a doctor with regard to their pain. Other research shows that up to 30% of workers with conditions such as rheumatoid arthritis (RA) are reluctant to disclose their condition to their colleagues and managers because they fear discrimination . The stigma associated with non-disclosure may also lead to increased mental distress as well as ‘presenteeism’ – the tendency of workers to go to work when they are ill enough to stay at home.


In the following sections, we will study the workability impact of three distinct MSDs – work-related upper limb disorders (WRULDs), back pain and RA.




Work-related upper limb disorders


The Global Burden of Disease data indicate that neck pain accounts for the fourth largest proportion of YLDs of all health conditions across the world. Just over 22.8% of European workers report that they have experienced muscular pain in their neck, shoulders and upper limbs . Whilst no agreed classification of WRULDs exists, there is a common consensus that symptoms of WRULDs can present in the tendons, muscles, joints, blood vessels and/or the nerves and may include pain, discomfort, numbness and tingling sensations in the affected area. These conditions can be caused, or exacerbated, by working which involves repetitive movements, prolonged keyboard use, heavy lifting, poor posture or other forms of work-related physical strain.


Almost all symptoms and impacts on work associated with MSDs are associated with WRULDs. Research has investigated the links between the physical and psychosocial aspects of WRULDs . This has highlighted that workers with upper limb, neck and shoulder pain are likely to experience more prolonged work disability and find RTW after a period of absence more difficult if their psychological well-being is also poor. It also suggests that ergonomic changes to the work environment, while important, will rarely be the main pillar of a successful job retention and vocational rehabilitation strategy unless aspects of psycho-social health are also addressed including job design which promotes control, task discretion and employee involvement. The EWCS (2005) has collected self-report data from workers who attributed muscular pain in their neck, arms and shoulders to their work. These findings are presented in Fig. 1 .




Fig. 1


Work-related upper limb pain: self-reports from European workers.

Source: Parent-Thirion et al., 2005 .


These data show considerable differences between countries. While cross-country comparisons are difficult, a handful of studies at the national level have illustrated the prevalence and impact of WRULDs in European countries:




  • The prevalence of repetitive strain injury (RSI) in the Netherlands stood at about 27% in 2006 .



  • Research in Belgium has identified that although workers in Belgium are slightly less likely than other European workers to have WRULDs, many of the symptoms have both a physical and psychological dimension. This can not only include traditional ergonomic factors such as repetitive motion, force or posture, but also workplace ‘stress’, control over the pace of work and job satisfaction.



  • Studies in Norway have identified that 54% of the workforce use a computer for at least half of the working day and that this may be associated with the relatively high prevalence of WRULDs relative to other European countries .



The research tells us that aspects of the physical work environment (e.g., ergonomic design) and the psychological health of the individual worker can have a decisive impact on both the degree of work disability and the ease with which successful RTW can be achieved. It is possible that, for a proportion of workers with WRULDs, work by itself may not be the only cause of their condition.




Low back pain


Back pain is common, episodic, often recurrent and generally self-limiting. It ranks as the health condition with the highest impact on YLDs in the Global Burden of Disease. Recorded absence is greatest amongst the minority of sufferers whose condition is chronic – if pain lasts for more than 12 weeks – or recurrent – if there are several episodes of pain in one year lasting <6 months. Most people who are affected by back pain either remain in work or return to work promptly. About 85% of people with back pain take <7 days off, yet this accounts for only half of the number of working days lost. The rest is accounted for by the 15% who are absent for more than 1 month .


There is a growing consensus that psychological factors are the differentiating factor as they are strongly associated with the progression of back pain from an acute to a chronic condition that affects 2–7% of people , and to disability .


The EWCS collected self-report data from workers throughout Europe on the prevalence of back pain attributable to work. Fig. 2 shows the percentage from each country reporting any degree of work-related back pain in the year prior to the survey.




Fig. 2


Work-related backache: Self-report from European workers.

Source: Parent-Thirion, 2005 .


These data suggest relatively low prevalence in northern European countries, with Greece, Slovenia and Romania reporting the highest proportion of workers with back pain. In most countries, there is also an industrial and occupational pattern to the prevalence of chronic back pain. These obviously reflect the physical nature of work and job demands that require lifting (construction and some health care occupations) or those where the risk of physical strain and poor posture is high.




Rheumatoid arthritis


RA is an example of a specific and progressive MSD. It is a form of inflammatory arthritis with a prevalence of between 0.3% and 1% in most industrialised countries . Data on the prevalence of RA were obtained largely from studies performed in the USA and Europe. The disease affects people of any age, although peak incidence is in the mid-age range of the working-age population, between 25 and 55 years. Epidemiological studies have shown that RA can shorten life expectancy by around 6–10 years.


Whilst the clinical course of RA is extremely variable, its features include pain, stiffness in the joints and tiredness and fatigue, particularly in the morning or after periods of inactivity. It affects the synovial joints, producing pain and eventual deformity and disability. The disease can progress very rapidly, causing swelling and damaging cartilage and bone around the joints. It can affect any joint in the body, but it is often the hands, feet and wrists that are affected. RA can also affect the heart, eyes, lungs, blood and skin.


RA can go from a mild and even self-limiting form to being severe and destructive within a short time . It is usually chronic (persistent) and sufferers often have ‘flares’ of intense pain frequently associated with fatigue. ‘Flares’ mean that one day someone will be able to perform everyday physical activities (e.g., dressing) or their work duties, and the next they cannot. Managing these ‘flares’ in employment requires close communication and understanding between employees and employers.


Table 1 shows prevalence and incidence data from a cross-national review . These data illustrate a consistent finding in RA research that prevalence is generally lower in the Southern European countries than in Northern Europe.



Table 1

RA prevalence and incidence in Southern and Northern Europe.































































Country Prevalence rates Incidence rates
North Europe England 0.9–1.1 0.02–0.07
Finland 0.8 0.03–0.04
Sweden 0.5–0.9
Norway 0.4–0.5 0.02–0.03
Netherlands 0.9 0.05
Denmark 0.9
Ireland 0.5
South Europe Spain 0.5
France 0.6 0.01
Italy 0.3
Greece 0.3–0.7 0.02
Bulgaria 0.9
Yugoslavia 0.2

Source: Alamanos, 2006 .


The effects of the disease can therefore make it difficult to complete everyday tasks, often forcing many people to give up work. Work capacity is affected in most individuals within 5 years . One review of work productivity loss due to RA estimated that work loss was experienced by 36–85% of people of working age living with RA in the previous year, for an average (median) of 39 days . Young et al. reported that 22% of those diagnosed with RA stopped work at 5 years because of RA. However, in some cases, the condition itself is not the main or only cause of having to leave work. Indeed, Young et al. found a further group of respondents who stopped work due to a combination of RA and other factors such as depression, giving an estimate of 40% of those with RA withdrawing from the workforce because of their condition. Every third patient with new RA becomes work disabled – people in poor countries remain working with high levels of disability and disease activity .


Patient surveys also reveal the work experiences of people with RA. A survey conducted by Arthritis Ireland provides further insights into the impact of the condition on employment. In 2008, a survey of people with RA showed that 70% were not able to work outside home because of their condition and that the annual cost of lost productive time due to RA was estimated to be €1.6 billion . A second survey, this time including Irish people with other forms of arthritis, showed that 67% of those who did not work or worked part-time stated it was because of their condition and that almost half had changed or left employment because of arthritis. Among those not employed, over 60% were considering returning to work, though 57% felt that fatigue represented their biggest barrier for returning to work. A survey in 2007 by the UK National Rheumatoid Arthritis Society (NRAS) showed that people’s working lifetimes appear to be significantly curtailed because of RA. Of those surveyed who were not in employment, nearly two-thirds (229 out of 353, or 65%) stated that ‘ they were not in employment because they gave up work early as a result of their RA. This includes people above and below statutory retirement age. This represents 29 per cent of all respondents (229 out of 782). ’ Whilst a high proportion cited pain and physical limitations as factors affecting their ability to perform their duties, 11% of those respondents who were employed and 17% of respondents who were unemployed cited a lack of understanding or support as a barrier to job retention. The report goes on to say that ‘ of respondents who had had to give up work early because of their RA, 13 per cent (30 out of 229) said that their employer had wanted them to leave once they became aware of the respondent having a long term health problem . The NRAS survey also highlighted that the majority of those with RA would like to remain in work.


The scenario in many other European countries supports the view that RA can have a damaging impact on the health and labour market participation of people of working age:




  • About 16% of RA patients in Lithuania have withdrawn from the labour force after 1 year of the onset of the disease and almost 50% after 10 years .



  • In Germany, 42% of female and 58% of male RA patients are employed(18–60-year-olds). About 76% of males with RA between the ages of 18 and 40 are employed, compared with only 46% of males between the ages of 51 and 60 .



  • The prevalence of RA in Greece is 0.68%. The prevalence rate increased significantly as age increased up to the 50–59-year-old age group. Individuals aged 50–59 years had the highest prevalence rate of 1.2% .



  • Czech data reveal that the annual incidence for RA was 31 per 100,000 adults aged 16 or above. The prevalence rate of RA was shown to be 610 per 100,000 adults aged 16 and above.



These data show that most people are affected with RA when they are of working age, undermining the myth that it is predominantly a condition of the retired or elderly.




The impact of the workplace on MSDs


The risk factors for MSDs are wide ranging. Whilst there is a broad consensus among experts that work may be a risk factor for MSDs, non-work activities such as sport and housework can contribute to musculoskeletal strain. Some studies, for example, have noted that a higher prevalence of musculoskeletal pain among working women may be linked to the fact that women are still mainly responsible for doing the majority of housework . In addition, caring responsibilities can also increase the risk of MSDs; carers frequently report back, neck and shoulder problems associated with lifting, washing and bathing activities. Intrinsic risk factors also have a part to play in the onset and deterioration of MSDs. Some intrinsic factors can be altered while others, such as genetic predisposition, cannot.


In terms of evidence and risk factors for the impact of work on MSDs, a distinction needs to be made between ‘work-related’ disorders and ‘occupational’ disorders . Certain MSDs are recognised as occupational diseases by some European governments, such as wrist tenosynovitis, epicondylitis of the elbow, Raynaud’s syndrome or vibration white finger and carpal tunnel syndrome . As such, the fact that work can cause and contribute to these conditions is widely recognised and the use of assessments of workplace risk to reduce the incidence of these conditions is well established.


The evidence linking other nonoccupational MSDs and work is not conclusive, and attributing cause and effect between specific aspects of work and particular parts of the body is difficult. However, many of the established risk factors that may contribute to the development of nonspecific musculoskeletal conditions can be encountered at work; even if work does not cause a condition, it may aggravate it. Moreover, if we consider risk factors beyond the physical, then the impact of the workplace on MSDs is likely to be much greater. The most frequently cited risk factors for MSDs encountered in the work place include the following:




  • Rapid work pace and repetitive motion patterns



  • Heavy lifting and forceful manual exertions



  • Non-neutral body postures (dynamic or static), frequent bending and twisting



  • Mechanical pressure concentrations



  • Segmental or whole-body vibrations



  • Local or whole-body exposure to cold



  • Insufficient recovery time .



Many jobs involve activities that can constitute a risk factor for MSDs. The EWCS reports that 17% of European workers are exposed to vibrations from hand tools or machinery for at least half of their working time, 33% work in painful or tiring positions for the same period, 23% carry or move heavy loads, 46% are subjected to repeated hand or arm movements and 31% work with a computer .


The European Agency for Safety and Health at Work indicates that the following industry sectors have the highest rates of WRULDs across Europe:




  • Agriculture, forestry and fishing



  • Manufacturing



  • Construction



  • Wholesale and retail



  • Hotel and catering.



Similarly, the Economic Dimension of Occupational Safety and Health (ECOSH) highlights the following high-risk occupations:




  • Manual workers and craftsmen



  • Machine operators



  • Secretaries and typists



  • Packers.



Much of the attention that employers pay to the issue of MSDs and the impact of the workplace on their onset or deterioration is driven by a concern to avoid or limit litigation and ensure that they are fulfilling their legal duty of care, by performing workstation assessments and giving guidance on manual handling. However, this neglects a wider issue that other work-associated factors can also contribute to MSDs. These aspects are often missed out in the literature and advice on dealing with health and safety. Even where ‘stress’ is mentioned, the connection between psychosocial factors and physical conditions is often omitted, reinforcing the primary focus on safety . Up to one-third of people with MSDs also present with comorbid mental illness such as depression or anxiety . Not only can this impede functional capacity, it can also inhibit job retention and RTW.


Generally, there is an increased risk of injury when any of the physical risk factors mentioned above are combined, or adverse psychosocial factors, personal or occupational are present . Psychological and organisational factors can also combine with physical factors to influence the probability that someone with MSDs will leave work prematurely. For example, Sokka and Pincus reviewed 15 studies and showed that physically demanding work, a lack of autonomy, higher levels of pain, lower functional status and lower educational levels were predictors of an RA sufferer leaving work early. This highlights that it is not only the physical elements of work that can influence someone’s functional work capacity and likelihood of staying in the labour market but also the psychosocial and organisational factors, which are as follows:




  • Rapid work pace or intensified workload



  • Perceived monotonous work



  • Low job satisfaction



  • Low decision latitude/low job control



  • Low social support



  • Job stress



Job stress is a broad term and can result from a variety of sources such as high job demands, a mismatch between skills and job requirements or abuse or violence at work. While job stress might lead to lost productivity, it may also lead to MSDs caused by tension or strain. An increased probability of experiencing a high level of pain has also been associated with low social support, low social anchorage or low social participation . ‘Good work’ and the provision of high-quality jobs are therefore crucial .

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Nov 10, 2017 | Posted by in RHEUMATOLOGY | Comments Off on Economic impact of musculoskeletal disorders (MSDs) on work in Europe

Full access? Get Clinical Tree

Get Clinical Tree app for offline access