CPD: Developing a return-to-work strategy for osteoarthritis

Osteoarthritis (OA) affects some 10% of men and 18% of women over the age of 60, and can make sitting, standing and tasks requiring manual dexterity difficult. Rachel Chakadonna and Professor Anne Harriss outline the role occupational health can have in supporting a worker with OA to stay in, and return to, the workplace.

Osteoarthritis (OA) is a long-term condition causing stiff, painful joints affecting 8.5 million people in the UK (IOSH, 2017). It can significantly impact on activities of daily living (Schlenk and Shi, 2019) such activities includes work tasks.

Worldwide, OA is the most common joint disease, affecting 10% of men and 18% of women over the age of 60 (Glyn-Jones et al, 2015).

About the authors

Rachel Chakadonna is a specialist occupational health nurse and Professor Anne Harriss is emeritus professor in occupational health and president-elect of the Society of Occupational Medicine

In 2013, 7.3 million people sought treatment for OA in England, equating to 33% of the population over the age of 45 years of age with significant implications for the workforce because of the increases in the state retirement age.

As the condition progresses, joint pain increases in duration and intensity, adversely affecting a person’s mobility. Everyday tasks including sitting, standing and undertaking tasks requiring manual dexterity become increasingly difficult.

This case study examines the effects of OA on “Annette” (not her real name), a 60-year-old woman employed to prepare in-flight food for an airline. It highlights the strategy to assist her to return to work.

Annette was referred for an occupational health (OH) opinion prior to returning to work following a six-month period of sickness absence. Before discussing how this case was managed it is important to understand the pathophysiology of this condition.

Pathophysiology

Although any joint can be affected, OA is a progressive disease generally affecting the joints of the hip, knee and hands causing moderate to severe pain and functional limitations (Schlenk and Shi 2019).

There is a hereditary component and an association with an increased body mass index (BMI). Other risk factors associated with its development include: gender (being female), advancing age (Sinusas, 2012) and bone injuries (Schlenk and Shi, 2019).

Chen et al, 2017 observe that occupations with work tasks requiring extensive standing and walking can predispose post holders to OA. However, other studies consider that occupational standing and walking has minimal effects. Having an elevated BMI is a risk factor for OA as it reduces joint flexibility and muscle weakness (Schlenk and Shi 2019).

The most common symptoms of OA include stiff, painful joints, with limitations in movement (Dulay, 2015).

The symptoms described by Annette were consistent with this picture. The pathogenesis of osteoarthritis is complex, resulting from an interplay of cellular, biochemical, mechanical, and biochemical elements (Hunter, 2011).

The pathophysiological changes affect both the joint cartilage and associated tissues. The cartilage covering the bones degenerates, typically at the point of maximum load bearing.

Osteophytes consisting of ossified cartilage form along with thickening of the synovium, the inner layer of the joint capsules which produces synovial fluid. The function of this fluid is important during movement as it reduces friction between the articular cartilage within the joint. Eventually, thickening and contraction of the joint capsule and ligaments occurs.

Under normal circumstances, joint structures are subjected to a dynamic remodelling process. In joints affected by OA, the protective articular cartilage of the bones breaks down, matrix degrading enzymes are overstretched, and pain results (Sinusas, 2012).

Carek, (2018) highlights erosion of the superficial layer of the articular cartilage eventually progresses into deeper layers with observable joint swelling, erosion and eventual joint failure.

Other writers consider that micro tears, cartilage degeneration and thickening underpin the joint pain. A combination of extrinsic and intrinsic factors, including joint overuse and degeneration from the ageing process, have been associated with the pathophysiology of OA (Thompson et al 2014).

The severity of symptoms varies between individuals (Irving et al 2005), with some sufferers experiencing more continuous pain and incapacity and some activities including gentle exercise reducing pain and improving function (Carek et al, 2018). An appreciation of the pathological changes is important when undertaking a client assessment.

Assessment

Annette had worked in aviation catering for 35 years enjoying her job working within a 40-member team. Prior to her current illness Annette had had no significant medical issues.

She had taken minimal sickness absence in the past 12 months and her BMI was within normal range. Living alone, she undertook all household chores, which now exacerbated her joint pain, although she continued to be a regular gym user, reporting that gentle exercise assisted in relieving her joint stiffness.

The framework of Murugiah et al (2002) was used to assess Annette’s fitness to work, with the outcome of that assessment forming the basis for workplace recommendations.

Personal and work-related aspects, including characteristics of the work processes she performed and the environment in which she worked, were carefully considered and viewed in the light of legal requirements. The severity of her symptoms, activities provoking or relieving her symptoms, and the treatment she was receiving, were recorded (Elliot & Coventry 2012).
Annette described having painful hands, with her tender finger joints affecting her manual dexterity.

In addition, she had a more recent, two-month history of pain affecting both shoulders, and her right hip. The extent of her hip pain was obvious as she was observed struggling to sit down.

She highlighted difficulties associated with lifting heavy items, standing and walking for long periods. She was increasingly experiencing stiffness and pain occurring throughout the day, particularly following periods of inactivity. These symptoms are consistent with OA (Irving et al, 2006). Annette mentioned that swimming tended to reduce her joint stiffness but this usually returned 3-4 hours later affected her mobility.

She had consulted her GP on first experiencing the symptoms, which affected her quality of life. Her doctor suggested the application of heat pads to her painful joints, taking paracetamol and ibuprofen as analgesia, and continuing to participate in regular exercise.

The recommendation by her GP for the use of over-the-counter medication led Annette to believe her GP was underestimating the severity and impact of her pain.

Annette had continued to manage to work her full operational hours and job requirement, despite increasing hip and shoulder pain, which was particularly problematic at the end of her shift.

She again consulted her GP, who ordered X-rays and magnetic resonance imaging tests, which confirmed a diagnosis of OA. She was prescribed naproxen, a non-steroidal anti-inflammatory drug to supplement the paracetamol Annette was already taking.

Reducing household chores and practising gentle exercise to control joint stiffness was recommended. Her GP initially issued a fit note for two weeks, with a review appointment.

Her symptoms, however, were of such significance in relation to her being able to perform her job requirements that this was extended, and Annette was eventually absent for a total of six months.

Assessing fitness for job role

Functional capability assessments must be undertaken in the light of the employee’s job role and possible exacerbating factors. This required detailed knowledge of Annette’s job requirements; her typical duties and working environment; and an appreciation of the departmental policies, procedures and organisational culture and in the light of statutory requirements (Murugiah et al 2002).

Annette worked a 40-hour week on rotating shifts. From an ergonomic perspective her work was physically demanding, required standing for extended periods whilst stretching, and lifting packed food trays which were then placed on trolleys.

Engel’s (1977) biopsychosocial model of health was used to focus on the interplay of biopsychosocial factors that might impact on her health. This model considers the individual’s social and psychological background and health status in the light of their work environment (Waddell and Burton 2006).

The impact of social and psychological factors are important considerations when developing return to work (RTW) strategies and consideration of clinical flags is useful (Watson, 2010).

Coloured flags representing clinical and psychosocial elements include:

  • Red. Features of the clinical condition.
  • Blue. The extent of organisational support.
  • Black. External factors impacting on the employee such as financial considerations.
  • Pink. Biological factors including pain, affecting the ability to undertake work tasks.
  • Yellow. Psychological factors including negative thoughts, beliefs and perceptions

Psychological aspects may significantly impact on an effective RTW should there be negative attitudes of co-workers and/or managers as a lack of support negatively influences the decision of the employee regarding their motivation to return to work.

Fitness to work assessment

The health and wellbeing initiatives provided by Annette’s employer included a nurse-led OH service and access to on-site physiotherapy.

The organisation generally acted positively on OH advice regarding suggested adjustments to support early returns to work. Employees were eligible for full salary over the time-limited period when they undertook recuperative duties.

Annette’s manager recognised that OH referrals for assessment supported a successful RTW. At the point Annette’s GP considered her fit to return to work. Therefore, the manager requested an assessment of her fitness to work and for advice on modifications that might support and sustain her return.

It was recognised that a timely return was in the interest of both the individual and the organisation, as good health is good for business (Health and Safety Executive, 2000; Chartered Institute of Personnel and Development, 2015).

The longer an employee remains away from work, the less likely they will return and their health will deteriorate further. Early interventions and employer support reduce ill-health related job losses (Viikari-Juntura (2012), Krause (2008).

Two of the key management strategies in supporting employees back to work following long-term absence are keeping in touch with them during their absence and engaging early OH advice and support and consideration of flexible/modified hours on their return (Ståhl, 2013, Nevala, 2015).

Unfortunately, in Annette’s case, a referral to OH was only made after a six-month period of absence; an earlier referral would have been preferable as early (OH) support enhances a timely and successful return to work (Black, 2017).

Supporting staff back to work is not just paternalistic, but is in the interest of the organisation. Retaining experienced employees is more cost effective than recruiting then training replacement staff (Cullen, 2018).

There are also public health benefits. As Black and Frost (2011) note, remaining in employment benefits mental and physical health and wellbeing.

Work provides a sense of purpose, builds self-esteem, and provides opportunities to build work relationships. Supporting those with health challenges to stay in work has the potential to reduce health inequalities, as these people are less likely to experience financial constraints. The financial burden on the employee can be minimised by facilitating an effective return to work (Waddell and others, 2008). Short-term job adjustment to duties or hours are often required to support such an early return.

The framework of Murugiah et al (2002) in assessing fitness for role was used to assess Annette’s fitness for role and particularly the impact of pain on Annette, as this takes into consideration her work environment, personal characteristics, and the legal aspect of fitness to work.

Personal aspects were assessed through clinical observations using a structured clinical assessment of her functional capabilities. A holistic, comprehensive, history was recorded, as suggested by Thornbory (2013) and Waddell & Burton (2004), while potential obstacles to an RTW were noted (Kendall et al, 2009).

Occupational health referral and advice

Had Annette been referred to OH at the point her symptoms first began to impact on her activities of living, her ability to perform her work tasks and prior to her period of absence, blue flag factors regarding her perceptions of the relationship between her work and her health could have been identified and addressed.

This may have reduced her subsequent sickness absence had they been addressed. Job tasks that may have exacerbated her joint pain could have been identified and addressed. The OHN sought to understand the full range of social, psychological and biological factors affecting Annette in order to affect a timely recovery and return to work plan (Thornbory 2013). A comprehensive, holistic assessment was therefore undertaken and recorded.

Long-term considerations

As Annette was already experiencing moderate to severe pain affecting multiple joints, it was recognised her condition could become increasingly debilitating.

She welcomed advice on how to best manage her condition, including recognising and then addressing factors that might exacerbate or relieve her pain.

She was referred for physiotherapy with the aim of improving her flexibility. She was advised of the importance of appropriate gentle exercise, such as walking. The OH assessment identified that Annette’s job role required prolonged standing and lifting, and thus a return to full operational hours undertaking static tasks and lifting and moving heavy loads were inadvisable. This formed the basis of advice that was given to both Annette and her manager.

Although very keen to return to work of some type, Annette was anxious about returning to her previous physically demanding role.

She anticipated getting insufficient support from work colleagues and that she would be unable to cope as a result.

As any negative perceptions by an employee regarding their return to work may significantly affect their timely return, it was important to preserve Annette’s positive attitude whilst considering the impact of workplace issues including relationships with her manager and co-workers.

A return-to-work plan was therefore developed, incorporating a period of recuperative duties and adjustments to her operational hours. This formed the basis of the OH report her manager had requested.

It was left to the manager to decide whether these recommendations could be facilitated and, if so, how they would be implemented.

It is good practice for any return to work strategy to consider appropriate recommendations, irrespective of whether the Equality Act 2010 might apply. That said, the manager should remain mindful that whether this Act would apply is a legal rather than a medical decision. An important factor was that the effects of OA will last for more than 12 months.

Supporting a return to work

Annette was able to return to work as a result of her manager implementing the workplace adjustments recommended by the OHN. The suggested modifications incorporated:

  • Temporarily adjusted working hours for a period of four weeks;
  • Limiting the manual handling of heavy or unwieldy loads; and
  • Scheduling regular rest periods during her working day to minimise the time she spent standing to undertake work tasks.

These adjustments were developed as a result of the OHN understanding Annette’s health and the impact of her work requirement. Her return to work was based on the knowledge of her functional capabilities, her work requirements and wellbeing support she was able to access.

The recommendations made incorporated an evidenced-based rehabilitation programme as proposed by Kendall et al (2009). Subject to continued improvement of her symptoms, it incorporated work hardening by gradually reintroducing her normal working hours and more physically demanding work tasks.

As multiple joints were affected a full recovery was unlikely. However, a likely improvement in her functional capabilities was likely with support from the occupational physiotherapist, and a referral was arranged.

There is strong evidence on the effectiveness of proactive, early vocational rehabilitation interventions (Waddell and Burton, 2006).

These are advocated as the longer the period of absence the greater the obstacles to returning to work. Key to return to work strategies is effective communication between the manager, employee and OH service underpinned by the application of well formulated and supportive sickness absence policies.

Legal aspects were considered when advising Annette’s manager regarding her fitness to work; a phased return to work was recommended. He remained cognisant of his duty of care to his workers under S2 of the Health and Safety at Work etc Act (1974) and was careful to ensure, as far as reasonably practicable, the health, safety and welfare of the team he manages. He acknowledged that developing an appropriate RTW strategy took account of this duty.

Outcome

After four weeks of temporary adjustments Annette reported a successful return to work, indicating that her line manager had been very supportive. He had agreed permanently to adjust her hours and she was redeployed to a less physically and mentally challenging part of the production process.

Annette had completed four sessions of physiotherapy and continued with the prescribed exercises in between sessions. Annette confirmed that she was taking her prescribed analgesia and was continuing to swim. These helped in keeping her joint pain under control. She reported feeling psychologically well, was pleased to be back at work and that her family were assisting her with domestic duties.

Conclusion

The fitness to work assessment required specialist knowledge and expertise and incorporated holistic approaches.

An understanding of the aetiology, pathophysiology, and presenting symptoms coupled with a detailed knowledge of the organisational purpose, environment, culture and roles to be undertaken proved essential.

Annette made a successful return to work. Both Annette and her manager were aware that she could be re-referred should her health impact on her work performance or her work impact on her health.

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