The impact on the individual

There is now greater acknowledgement of the benefits of work participation for the individual. A number of reviews have highlighted the benefits of work participation and the importance of ‘good work’ to health and well-being . ‘Good’ work implies several attributes: safety, personally rewarding and work demands that do not exceed the capabilities of the worker. Extensive background evidence suggests that working at a job with these positive attributes is generally good for physical health, mental health and well-being; it is beneficial to an individual’s prosperity and is important to psychosocial needs in societies where employment is the norm. It is central to identity, social roles and social status, and employment and social status are the main drivers of social gradients in physical and mental health and mortality . However, jobs with high levels of mental stress and physical demands are associated with negative health effects, such as increased risk for work-related injury . In contrast, involuntary exclusion from employment is associated with significantly poorer overall self-rated health, more depressive symptoms and a greater decline in health status, (although these are also reasons for being out of work) . The general view of work being positive for individuals has encouraged clinicians and policy makers to focus on improving work participation through preventing premature work cessation (i.e., prior to retirement age) and encouraging return to work. Improving or maintaining work participation is encouraged as a target for working age adults with rheumatic conditions.

The size of the burden

There is considerable evidence of the size of the adverse impact of rheumatic conditions on work. Impact can be described in terms of:

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  Work disability – ceasing to work before retirement age;

  
  
• •
  

  Absenteeism – missing part or whole days from work (e.g., number of days/hours off work); and

  
  
• •
  

  Presenteeism – an individual remains in work but with difficulty or reduced efficiency/productivity.

Short-term absenteeism and presenteeism contribute to the indirect costs of rheumatic diseases, but are not considered as much by policy makers, who usually focus primarily on direct costs based on health-care usage and long-term disability directly attributed to rheumatic conditions. Work productivity loss due to presenteeism is estimated to be far greater than absenteeism . Estimates of presenteeism vary depending upon the measuring tool, and measuring productivity accurately is challenging. The following sections provide an overview of impact of rheumatic conditions on work, taking rheumatoid arthritis (RA) (the most common auto-immune disease), low back pain (the most common musculoskeletal condition affecting working age adults) and osteoarthritis (OA) (the most common form of arthritis) as examples.

Rheumatoid arthritis

The impact of auto-immune joint disease on work ability is high. Taking RA (where 60–75% of people are of working age at diagnosis) to illustrate this, adults with RA take 46 days off per year compared to a population average of 8.5 days . The number of days of sick leave per year is strongly associated with risk for permanent work disability (i.e., ceasing to work prior to retirement age) . One in four people (23%) who is diagnosed with RA stop working in the 3 years following diagnosis . This increases to one in three (35%) by 10 years and more than half (51%) of those with duration longer than 25 years will have stopped working pre-retirement age. The annual incidence of work disability is 10% . Once out of work, most people with RA never return to work . However, the prevalence of work disability is decreasing; previously, 50% of newly diagnosed RA cases had work disability within 10 years of diagnosis. This is a consequence of improved treatment, changes in the nature of employment and perhaps improved conditions in the workplace, which is also evidenced by an increasing rate of return to work . The reduction in the proportion of those with RA permanently leaving the workplace may result in an increase in presenteeism; individuals are remaining in work but with limited capabilities. Currently, 34% of workers with RA report a decrease in productivity due to their condition, although comparable data are not available over the past decade to determine whether this is an increasing trend .

Non-inflammatory conditions – low back pain

Although the impact of inflammatory arthropathy on the individual is often much greater, the cumulative burden of non-inflammatory arthropathies and disorders, such as back pain, OA and limb pain, as a whole results in much greater total economic and human cost to society. Taking low back pain to illustrate this point, whilst the prevalence of RA in the United Kingdom is 0.81%, low back pain affects over one-third of adults at any one time, and each year approximately 3.5 million people in the UK develop a new episode of back pain . It is the most common reason for middle-aged people to visit primary care, with approximately 6–9% of adults consulting for this condition each year . Although many back pain patients stop consulting their general practitioner (GP) within 3 months, 60–80% of people still report pain or disability a year later, and up to 40% of those who have taken time off work will have future episodes of work absence . In the United Kingdom, the annual cost of absenteeism due to low back pain is estimated at 1% of the gross domestic product . The impact of presenteeism due to low back pain may well be higher due to lost productivity.

Non-inflammatory conditions – OA/joint pain

OA is associated with work limitation, sick leave, being out of work (unemployment) and early retirement . Those with OA take a significantly greater number of sick leaves per year compared to the average for the general population (9.6 cf 8.5 days) . Although the effect on work for individuals tends to be smaller than that for RA , the sheer frequency of people with OA means that it has a larger impact on work. Like low back pain, OA and its main symptom (joint pain) is common in adults aged 50 years and over (i.e., the annual prevalence of knee pain is 46% in those over age 50) . The effect of OA is more on presenteeism than absenteeism . In those with knee pain, around one in five patients indicate problems at work . Reduced productivity is 3–5 times more likely in those with OA than in those without . Three-quarters of working adults with OA make some changes to their work situation to maintain their participation in work .

Extensions to working life

Policies to extend working life have become a central response to ageing populations in developed countries. Delaying retirement is viewed as a means to mitigate the effects of worsening demographic ratios whilst increasing financial resources for later life. Such policies are important from a fiscal and social imperative. Many governments have raised pension ages along with a range of other measures such as anti-age discrimination legislation, to delay retirement. It is in this context that our ability to maintain the capacity of individuals with rheumatic conditions to remain in, or return to work is increasingly important. More than three-quarters of the population do not have disability-free life expectancy up to age 68 years. Much of this problem is attributable to rheumatic conditions . As the prevalence of rheumatic conditions increases with age and as working lives extend, there will be many more employees with musculoskeletal problems in the years to come; there will be more people in work coping with rheumatic conditions that compromise their work ability and productivity. The challenge is to keep individuals with rheumatic conditions in work, reduce the size of the impact of rheumatic conditions on work and contribute to the health and well-being of individuals.

The impact on the individual

There is now greater acknowledgement of the benefits of work participation for the individual. A number of reviews have highlighted the benefits of work participation and the importance of ‘good work’ to health and well-being . ‘Good’ work implies several attributes: safety, personally rewarding and work demands that do not exceed the capabilities of the worker. Extensive background evidence suggests that working at a job with these positive attributes is generally good for physical health, mental health and well-being; it is beneficial to an individual’s prosperity and is important to psychosocial needs in societies where employment is the norm. It is central to identity, social roles and social status, and employment and social status are the main drivers of social gradients in physical and mental health and mortality . However, jobs with high levels of mental stress and physical demands are associated with negative health effects, such as increased risk for work-related injury . In contrast, involuntary exclusion from employment is associated with significantly poorer overall self-rated health, more depressive symptoms and a greater decline in health status, (although these are also reasons for being out of work) . The general view of work being positive for individuals has encouraged clinicians and policy makers to focus on improving work participation through preventing premature work cessation (i.e., prior to retirement age) and encouraging return to work. Improving or maintaining work participation is encouraged as a target for working age adults with rheumatic conditions.

The size of the burden

There is considerable evidence of the size of the adverse impact of rheumatic conditions on work. Impact can be described in terms of:

• •
  

  Work disability – ceasing to work before retirement age;

  
  
• •
  

  Absenteeism – missing part or whole days from work (e.g., number of days/hours off work); and

  
  
• •
  

  Presenteeism – an individual remains in work but with difficulty or reduced efficiency/productivity.

Short-term absenteeism and presenteeism contribute to the indirect costs of rheumatic diseases, but are not considered as much by policy makers, who usually focus primarily on direct costs based on health-care usage and long-term disability directly attributed to rheumatic conditions. Work productivity loss due to presenteeism is estimated to be far greater than absenteeism . Estimates of presenteeism vary depending upon the measuring tool, and measuring productivity accurately is challenging. The following sections provide an overview of impact of rheumatic conditions on work, taking rheumatoid arthritis (RA) (the most common auto-immune disease), low back pain (the most common musculoskeletal condition affecting working age adults) and osteoarthritis (OA) (the most common form of arthritis) as examples.

Rheumatoid arthritis

The impact of auto-immune joint disease on work ability is high. Taking RA (where 60–75% of people are of working age at diagnosis) to illustrate this, adults with RA take 46 days off per year compared to a population average of 8.5 days . The number of days of sick leave per year is strongly associated with risk for permanent work disability (i.e., ceasing to work prior to retirement age) . One in four people (23%) who is diagnosed with RA stop working in the 3 years following diagnosis . This increases to one in three (35%) by 10 years and more than half (51%) of those with duration longer than 25 years will have stopped working pre-retirement age. The annual incidence of work disability is 10% . Once out of work, most people with RA never return to work . However, the prevalence of work disability is decreasing; previously, 50% of newly diagnosed RA cases had work disability within 10 years of diagnosis. This is a consequence of improved treatment, changes in the nature of employment and perhaps improved conditions in the workplace, which is also evidenced by an increasing rate of return to work . The reduction in the proportion of those with RA permanently leaving the workplace may result in an increase in presenteeism; individuals are remaining in work but with limited capabilities. Currently, 34% of workers with RA report a decrease in productivity due to their condition, although comparable data are not available over the past decade to determine whether this is an increasing trend .

Non-inflammatory conditions – low back pain

Although the impact of inflammatory arthropathy on the individual is often much greater, the cumulative burden of non-inflammatory arthropathies and disorders, such as back pain, OA and limb pain, as a whole results in much greater total economic and human cost to society. Taking low back pain to illustrate this point, whilst the prevalence of RA in the United Kingdom is 0.81%, low back pain affects over one-third of adults at any one time, and each year approximately 3.5 million people in the UK develop a new episode of back pain . It is the most common reason for middle-aged people to visit primary care, with approximately 6–9% of adults consulting for this condition each year . Although many back pain patients stop consulting their general practitioner (GP) within 3 months, 60–80% of people still report pain or disability a year later, and up to 40% of those who have taken time off work will have future episodes of work absence . In the United Kingdom, the annual cost of absenteeism due to low back pain is estimated at 1% of the gross domestic product . The impact of presenteeism due to low back pain may well be higher due to lost productivity.

Non-inflammatory conditions – OA/joint pain

OA is associated with work limitation, sick leave, being out of work (unemployment) and early retirement . Those with OA take a significantly greater number of sick leaves per year compared to the average for the general population (9.6 cf 8.5 days) . Although the effect on work for individuals tends to be smaller than that for RA , the sheer frequency of people with OA means that it has a larger impact on work. Like low back pain, OA and its main symptom (joint pain) is common in adults aged 50 years and over (i.e., the annual prevalence of knee pain is 46% in those over age 50) . The effect of OA is more on presenteeism than absenteeism . In those with knee pain, around one in five patients indicate problems at work . Reduced productivity is 3–5 times more likely in those with OA than in those without . Three-quarters of working adults with OA make some changes to their work situation to maintain their participation in work .

Extensions to working life

Policies to extend working life have become a central response to ageing populations in developed countries. Delaying retirement is viewed as a means to mitigate the effects of worsening demographic ratios whilst increasing financial resources for later life. Such policies are important from a fiscal and social imperative. Many governments have raised pension ages along with a range of other measures such as anti-age discrimination legislation, to delay retirement. It is in this context that our ability to maintain the capacity of individuals with rheumatic conditions to remain in, or return to work is increasingly important. More than three-quarters of the population do not have disability-free life expectancy up to age 68 years. Much of this problem is attributable to rheumatic conditions . As the prevalence of rheumatic conditions increases with age and as working lives extend, there will be many more employees with musculoskeletal problems in the years to come; there will be more people in work coping with rheumatic conditions that compromise their work ability and productivity. The challenge is to keep individuals with rheumatic conditions in work, reduce the size of the impact of rheumatic conditions on work and contribute to the health and well-being of individuals.

Factors that reduce work participation

The starting point for managing rheumatic conditions and work is to gain an understanding of the factors causing work loss as potential targets for interventions. These can be considered in the following categories:

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  Condition specific factors and physical limitation: Disease duration and symptom severity are linked to poor work participation. However, clinical factors add little to models of work disability that include physical function . This is because clinical factors indirectly affect poor work outcomes through their impact on physical function.

  
  
• •
  

  Co-morbidity: This factor contributes to work problems in those with joint pain . More notably, the co-occurrence of mental health problems with rheumatic conditions has a big impact. For example, many patients with musculoskeletal pain also suffer from depression , which is a key factor for developing chronic disabling pain . This combination is associated with increased absence from work and interventions, which reduce depression severity in those with chronic pain, increase return to work .

  
  
• •
  

  Socioeconomic and environmental factors: Low socioeconomic status, in terms of low income and low education, affects work participation through links with pain and health behaviour . Low socioeconomic status is also linked to more physical occupations and poorer working conditions which have an impact on rheumatic conditions and work participation. Living in areas of higher socioeconomic deprivation and low work opportunities is linked to increased work disability .

  
  
• •
  

  Psychological factors: In addition to mental health problems, psychological factors are a major obstacle to maintaining work participation and return to work. Examples of key psychological factors that impact on work are catastrophising, negative illness beliefs (false beliefs and pervasive thoughts about personal illness), low self-efficacy and lack of self–esteem .

  
  
• •
  

  As the phenomenon of work disability occurs in a social and environmental context, these factors have a significant impact on work disability. An individual’s beliefs and expectations about normal working life expectancy, access to disability and retirement benefits and appropriate social roles are shaped by their own experience and their immediate context. Key features may include availability of disability and retirement benefits, governmental regulations and programmes, advice from health-care providers and input from family and co-workers .

  
  
• •
  

  Occupational and workplace factors: Physically and mentally demanding and high-paced jobs have a negative impact on work participation for those with rheumatic conditions . A non-supporting work environment is a key factor; the lack of work accommodations (e.g., flexible and changes to working hours, adaptations to working practice and environment and use of aids and appliances), negative work culture and a lack of support from colleagues and managers is linked to absence and reduced productivity .

Models for organising predictors of work disability

Psychosocial and occupational factors are increasingly recognised as the key reasons for reduced work participation. A framework to organise and understand the psychosocial, occupation and workplace influences is offered by the ‘The Flags’ concept, which has been developed in the fields of occupational medicine and psychology . This system links with the clinical use of ‘red flags’ to highlight the existence of serious pathology (e.g., malignancy) and the need for immediate medical input. Three additional flags (yellow, blue and black) are warning signals that psychosocial factors in or around the individual are acting as obstacles to full recovery and return to work, and each flag points to specific reasons for work disability:

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  Yellow flags encompass psychological risk factors that are a consequence of musculoskeletal symptoms. These refer to beliefs, appraisals and judgements about pain (e.g., pain will increase with activity and treatment will not reduce pain) that lead to pain behaviour (e.g., fear avoidance of activities due to fear of pain and reinjury, over-reliance on passive treatment (e.g., analgesics)) and emotional responses (e.g., anxiety) that prevent return to work. These are important predictors for the development of long-term problems.

  
  
• •
  

  Blue flags refer to perceptions of the relationship between work and health at an individual level. Perceptions of work such as fear of exacerbation of symptoms or disease induced by the job, high perceived physical job demand and job-related stress reduce the likelihood of return to work. Perceptions of poor communication, a lack of support from supervisors or work colleagues and the little opportunity for job accommodations/modified work also reduce return to work.

  
  
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  Black flags are characteristics that are specific to an individual’s employer. Examples are unhelpful policies/procedures used by employers, such as the absence of a mechanism to provide alternate duty for employees returning from sickness absence, working practice that offers little opportunity for modification and conflict with insurance staff over injury claims. These are environmental factors that perhaps clinicians can do little about but must be aware of when managing patients’ work participation, as they can communicate with employers about the importance of addressing these issues.

The emphasis of this approach is to systematically identify and then categorise obstacles to returning to or staying at work, and then identify appropriate strategies for their removal or resolution. Additional guidance for the application of ‘the flags’ approach is outlined in a monograph . The different flags highlight the heterogeneity of issues with adults with rheumatic conditions leading to work problems.

Managing MSDs and work

The approach to managing musculoskeletal conditions and work is evolving. A coherent and effective response to the worker’s need for support in continuing to work or returning to work is necessary. A greater emphasis on a ‘joined up’ approach to the sick worker’s problems involving the worker, the multidisciplinary team (e.g., the rheumatologist, physiotherapist, occupational therapist, psychologist, occupational health professional and/or employer advisor) and the employer is required. Improving work capability in older adults with rheumatic conditions requires a multifactorial approach that addresses physical, psychological, social and occupational factors and focusses on managing the condition and associated co-morbidities rather than all taking a narrow focus on treating or ‘curing’ the condition . This is important as most people with MSDs have the potential to continue to work despite the persistence of symptoms.