There are around 200 types of arthritis, but not all have a readily identifiable name. This means that when someone says they have arthritis, it might not be the type that you are familiar with and therefore it may not affect them in the way you would expect. Lucy Kenyon explains how this could have an impact on the workplace.
A survey by the National Rheumatoid Arthritis Society in June 2013, coinciding with national rheumatoid arthritis week, revealed delays in identifying and treating arthropathies within the 12-week “window of opportunity”.
Despite this, a symposium on musculoskeletal disorders (MSDs) in the workplace on 16 June 2015, organised by Arthritis Research UK, reported that sufferers are continuing to experience difficulties in obtaining a diagnosis. The impact for employers is that employees without a diagnosis will have difficulty carrying out their job, regardless of diagnosis label.
Arthritis in the workplace: a brief discussion
Key messages from this article are to:
- reduce discrimination (dismissing or accommodating a condition on the basis of its clinical name);
- inform employers to identify and manage adaptations and adjustments; and
- improve attendance and performance by promoting musculoskeletal health.
The Government’s statistics from 2015 reported that 16% of cases for disability living allowance (Arthritis Research UK, 2015) and 20% of personal independent payment claims (gov.uk, 2015) were recorded with “musculoskeletal disease” as the primary disability condition. These are the numbers of people unable to carry out daily activities due to their incapacity.
Arthritis conditions fall into five main groups: inflammatory; degenerative; soft tissue musculoskeletal pain; back pain; and connective tissue diseases. Linked conditions (co-morbidities) include: carpal tunnel syndrome; chronic fatigue; depression; fibromyalgia; and inflammatory bowel disease. These are long-term conditions that will present as a gradual decline in physical ability, or appear as injuries to a joint or joints.
Symptoms are often misunderstood and misdiagnosed, because initially they present independently of joint pain, for example flu-like symptoms, apparent moving and handling injuries, or repetitive use of a set of muscles. They are also fluctuating conditions, and the relationship between presenting symptoms and other medical history may not be immediately obvious.
Many sufferers learn to live with their symptoms, not wanting to bother their GP, or see a different doctor each time they attend the surgery, meaning that their symptom pattern is not picked up. I often see employees who have been referred to me because of their short-term sickness absence pattern, or because a condition linked to arthritis (co-morbidity), such as depression, affects their work first.
Difficulties reported by employees suffering from arthritis include:
- not being able to perform all of their tasks;
- tasks taking much longer than they used to;
- the stress of their job, causing the condition to flare-up or make symptoms worse;
- not having the energy or stamina to work;
- getting fatigued easily; and
- not having the energy for things outside of work.
Employers know that “musculoskeletal disorders are major contributors to short-term absence” and are “the second most commonly identified cause of long-term absence for manual workers (37%), closely followed by chronic back pain” (30%) (CBI, 2015).
Fitness for work and the practicability of making adjustments for sufferers remains a key challenge for employers. In an increasingly competitive market, demands of work have increased faster than workers’ physical work capacity (or work ability).
Work disability where the cause is rheumatoid arthritis (RA) has decreased in line with the decrease in physically demanding work. However, “impairment of the shoulder, wrist, knee, and ankle significantly affects functional capacity in patients with RA”. Prevention of stress and injury to these joints is likely to improve functional outcomes and work ability (Tengland, PA, 2015).
Case study: managing arthritis in the workplace
The following case has been amalgamated from the author’s personal caseload. Some details have been changed to protect anonymity.
Mrs X is a warehouse supervisor for a supply chain company. Her job involves processing food and household items from suppliers for distribution to stores. Some of her work involves working in a chilled area of the warehouse. She has been employed by the company for 15 years.
Over the course of her employment, she has experienced a number of apparently unconnected long-term absences for back pain and carpal tunnel syndrome. More recently she has had short-term absences for stomach upsets and intermittent frozen shoulder, culminating in several weeks’ absence for depression and leading to a referral to OH as part of the attendance management procedure.
Risk assessments have been carried out in line with Health and Safety Executive guidance, and work procedures have been calculated on average pick rates. Although she has reported difficulties to her managers, little has changed. She has hit absence triggers and her case is being managed through a disciplinary and capability procedure.
On attending the OH department, she attributed her problems to work. As a supervisor, she has been responsible for attendance management of her team, and was angry with her employer for putting her on the disciplinary procedure. Consent was obtained to record her data and an assessment was carried out using the biopsychosocial model.
Over the years, she has seen her GP and been diagnosed with injuries to and arthritis in a number of individual joints, which she had been told to self medicate with painkillers. She has been prescribed an antidepressant, which she has been taking for a number of years.
Apart from having surgery to release her carpal tunnel, she has not been referred to a rheumatologist or orthopaedic specialist; and more recently has been started on hormone replacement therapy.
She reported feeling tearful, and was getting anxiety symptoms the night before her shifts, affecting her sleep and was struggling with the shift patterns. Relationships had started to deteriorate both at work and at home.
It transpired that she had applied for the job after being made redundant during a local economic recession. She had administrative skills, but had lost confidence in her abilities.
I made recommendations about working arrangements, adjustments and adaptations for management to consider, which I felt would enable Mrs X to return to and achieve at work, which included:
- annualised hours;
- adjustments to the work rate and shift pattern to accommodate her physical limitations;
- application for funding for adaptations and support and changes to the workstation;
- consideration for alternative employment to administrative, training or supervisory work through the internal recruitment procedure; and
- short-term issue-based counselling.
However, her employer was concerned about setting a precedent for others if adjustments were implemented.
At the same time, life expectancy has increased, adding pressure to pensions, and resulting in an increasingly ageing workforce. Age is not the only risk factor for musculoskeletal problems, as it brings the benefits of life-experience, work ethic and mentorship (Jessop, 2013); but older workers are inevitably more susceptible to work-related MSDs than younger workers, possibly because of decreasing physical exercise and functional capacity
An older workforce has implications for the health and safety responsibilities of employers (Health and Safety Executive (HSE), 2015). These include providing additional support for worker requirements, changing the workplace attitudes towards ageing, providing a positive knowledge base, adjusting the workplace design and accommodations and improving worker/employer relationships (cooperation).
Workability and arthritis
The recommendations in this article are based on a review of the evidence in 2013 (Nastasia et al, 2015), which recommended early screening and targeted intervention on physical, ergonomic, and biopsychosocial factors of (injured) workers to prevent prolonged disability and to promote effective, sustainable returns to work.
For employers seeking further information about adaptations and reasonable adjustments, supported by the Government’s Access to Work service, details are available from the HSE.
Risk factors affecting employees with arthritis, and work-related MSDs, include (Arthritis Research UK, 2015):
- repetitive and heavy lifting;
- bending and twisting;
- repeating an action too frequently;
- an uncomfortable working position;
- exerting too much force;
- exerting a force in a static position for extended periods of time;
- working without breaks;
- adverse working environment (eg being too hot or cold); and
- psychosocial factors (eg high workloads, tight deadlines, and lack of control).
Employer concerns and adjustments
One of the most common concerns among clients is the duration of a phased return. Most feel that they cannot support a phased return for the duration of a medical or vocational rehabilitation programme, and want to restrict it to within four weeks before the employee is back to full contractual duties and hours.
Evidence from the National Institute for Health and Clinical Excellence (NICE) shows that employees who return to work within a year of their initial absence are most likely to sustain a successful return to work when interventions are made.
A range of adjustments can be considered to accommodate a return to work and retention in the job.
Flexible shift patterns can help after diagnosis and early in the treatment plan by enabling employees to attend appointments for NHS health interventions, and to undertake exercise programmes.
Evidence supports this: “remission can be achieved using traditional disease-modifying anti-rheumatic drugs, and in those patients who achieved remission within six months, none were work-disabled at five years (Nikiphorou et al, 2012)”. These drugs need monitoring through monthly or quarterly blood tests, as well as regular consultant appointments until the condition has stabilised, when reviews are usually every six months.
Annualised hours schemes can enable employees to achieve contractual hours and duties while well. These schemes can also help reduce the possibility of employers needing to make interventions after employees reach trigger points for intervention – due to sickness absence, capability or breach of disciplinary policies.
Evidence of the link between physical demands of the job and disability supports the training and development of individuals with arthritis for more office-based and supervisory work, in order to retain knowledge, skills and experience within the workplace.
Health education can also support arthritis sufferers. Information and pdf posters can improve awareness of arthritis within the workplace and help employees self-refer, or be referred to, local NHS services, including:
- physiotherapy;
- counselling: workplace, NHS and industry-specific counselling services, for example retail trust, or teachersupport.net, for distribution by HR within communal areas; and
- NHS and voluntary support groups.
Problems that can arise
While NICE guidance (2015) to improve diagnosis and treatment of this condition remains in draft status, Arthritis Research UK is trying to remove the rheumatoid factor test from the diagnostic criteria, to improve treatment of the disabling symptoms. Seronegative arthropathies remain underdiagnosed, leaving individuals with disabling symptoms, but no diagnosis.
Many patients report being left in pain and claiming disability benefits, because their GPs tell them that lack of rheumatoid factor means that the disease is not present.
This inconsistency creates difficulties for employers, who will be more likely to view incapacity due to symptoms of arthropathies – pain, fatigue and depression, as a “won’t do” rather than a “can’t do”, or, worse still, as a psychosomatic illness.
Workplace strategies
Recommendations (Luttman et al, 2003) for supporting individuals with musculoskeletal disorders at work fall into four categories.
- Ergonomics
Jobs should be designed so that most people can carry them out. Movement is preferable to inactivity, but work overload should be avoided. The job should be fitted to the person, rather than the person to the job, and working conditions should always be adapted to the capacity of the worker.
- Work performance strategies
Employers should review outputs per hour and shift patterns. It is preferable for affected employees to work continuously at a moderate pace rather than work under intense time pressure over short periods.
- Workplace wellbeing programme(s)
Employee wellbeing programmes that will benefit workers with arthritis include:
- exercise to improve and increase stamina and strength (NRAS, 2015);
- canteen choices including fresh fruit and starchy foods;
- drinking water in the workplace;
- pre-work six-minute warm up, stretching or breathing exercise incentive scheme;
- salary sacrifice scheme to increase rest days between shifts;
- encourage walking to work for employees; and
- cycle to work schemes (Cyclescheme, 2015).
- Workplace training
Various forms of training are beneficial, including:
- cognitive behavioural return-to-work counselling programme for employees with short-term absences;
- problem-solving therapy (for about three hours a week for 15 weeks); and
- graded activity programmes including workplace visits and physiotherapy education and exercise three days a week to reduce time until return to work (NICE, 2009).
Other interventions for arthritis in the workplace
There are a number of tools used to assess musculoskeletal health that can be used to assess fitness for work of people with arthritis:
- DASH outcome measure (DASH 2015) (assesses disabilities of the arm, shoulder and hand);
- Integral Workplace Health Age management (I-WHAM) (Ageingatwork, 2015);
- S-factor awareness campaign (NRAS, 2015); and
- Work Ability Index (WAI) (2015)
Funding of medical treatments recommended to help employees return to work by Fit for Work and employer-arranged OH services carries a corporate tax exemption of up to £500 (per year, per employee); (UK Government, 2015).
Adjustments and adaptations and support services were explored in detail in a previous article on Autism in the Workplace (Kenyon L, 2015) in this publication.
Policies that can help retain people with arthritis in the workplace include:
- annualised hours;
- temporary redeployment or alternative work activities to support vocational rehabilitation, or promote skills or rehabilitation after a flare up; and
- time off /flexitime to attend a health improvement programme to improve performance or attendance, eg physiotherapy, or expert patient programme; (NHS, 2015).
Future management
Arthritis and musculoskeletal conditions significantly affect both the lives of individuals and the productivity of organisations. There is strong evidence that implementation of proactive health management policies, the use of health assessment tools to monitor the musculoskeletal health within organisations, and support for staff to use NHS services and support available will help employers and employees to work together to their mutual benefit.
Policy guidelines from NICE are already available, and are due to be published shortly, to help employers, and health, safety and employment professionals to promote and support people with long-term disabilities in the workplace.
It is recommended that health assessments are carried out by an occupational health service, to conform to data protection requirements, and that service providers are suitably qualified to identify individual risks and refer to appropriate medical management.
Bibliography
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National Rheumatoid Arthritis Society, “I Want To Work”. Web 11 August 2015.
Nice.org.uk, Draft. “Seronegative arthropathies: the diagnosis and management of seronegative arthropathies.” Web 11 August 2015.
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