Joint pain? Why we need a better evidence base for musculoskeletal disorders and work

What do we know about musculoskeletal disorders and work, and what do we need to know? Karen Walker-Bone looks at the challenges facing employers and occupational health practitioners when it comes to getting the evidence they need to understand, intervene and effectively manage MSDs and work.

As most occupational health professionals will well know, musculoskeletal disorders (MSDs) is an umbrella term used for a wide range of conditions affecting the bones, muscles, ligaments and joints, which together make up the strong, dynamic musculoskeletal system.

Ranging from localised sprains and strains, through to osteoporosis and osteoarthritis, these are common conditions that can cause pain and disability. Such is their ubiquity that we can all expect to experience painful symptoms from time to time, and Hadler has described them as a normal “predicament of life”.

About the author

Karen Walker-Bone is professor of occupational rheumatology and director at the Arthritis Research UK/MRC Centre for Musculoskeletal Health and Work

However, in some cases, pain becomes chronic and severe and may be associated with marked functional impairment. Many MSDs become more common at older ages so that the risk of disability attributable to these conditions increases with age.

What do we know?

1) Demographic changes

There have been marked demographic changes in higher-income countries of the world. Whilst longevity has increased, birth rates have dropped, such that the proportion of adults who are in work and economically productive has slowly been reducing relative to the proportion of the population who have retired.

Governments have responded to these changes by encouraging adults to work to older ages through legislative changes, such as abolition of the compulsory age of retirement and increasing the age threshold for being able to claim state pension. The inevitable consequence is that more people will be trying to work at older ages with prevalent MSDs.

2) Claims for disability

Amongst all OECD (Organisation for Economic Co-operation and Development) countries, the most recently available data show that the UK has the highest rates of new claims for disability per 1,000 of the working-age population.

It is not clear why the rates are higher in the UK but there are two main groups of health conditions responsible for work disability: MSDs and mental health. Therefore, it is clear that measures to encourage people to work despite MSDs and mental ill-health could impact importantly on work participation, particularly at older ages.

Moreover, five of the top six problems that impact work productivity are musculoskeletal or musculoskeletal-related (fatigue, depression) and MSDs have been estimated to cause 10 million working days to be lost annually and £7bn societal costs.

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What do we need to know?

1) Prevention of MSDs

Researchers have investigated risk factors for MSDs in different types of work over many years. Awareness of risk factors facilitates development of preventive strategies. Taking low back pain as an example, we have a good understanding of many of the common risk factors, which can be considered as personal, occupational and psychosocial factors (see below).

Personal factors

  • Increasing age
  • Obesity
  • Cigarette smoking
  • Family history
  • Parity
  • Structural (kyphosis, scoliosis)
  • Height
  • Low levels of educational attainment
  • Specific MSDs (for example osteoporosis or ankylosing spondylitis)

Occupational

  • Lifting
  • Working outdoors
  • Awkward posture
  • Whole-body vibration
  • Job dissatisfaction

Psychosocial

  • Depression
  • Anxiety
  • Stress at work
  • Poor job satisfaction
  • Low income

Whilst some of these risk factors are modifiable, others are less so or are not within the employers’ control (for example obesity).

Therefore, the focus has been on placing responsibility on employers to minimise exposure to the recognised physical workplace factors through ergonomics and mechanisation. Such approaches have undoubtedly had some impact but, to date, have unfortunately failed to substantially impact rates of low back pain or disability caused by low back pain.

Employers are increasingly interested in “wellness” and advocating healthy diets and exercise, as well as smoking cessation, which could also have a positive benefit on rates of low back pain. But there has been little in the way of evaluation of the effectiveness of these approaches on lasting behaviour change.

Therefore, although prevention remains the “holy grail”, we currently have little information to suggest that it is actually working. Evaluations of some ergonomic interventions (for example lifting equipment in hospitals) suggest limited or no impact on pain but also suggest that staff do not use the equipment as intended.

To get around this, “participatory” approaches to ergonomics are being applied in workplaces and in research. Such approaches start with a “bottom up” approach to workplace change with a common goal (for example reduction of back pain), asking those doing the work what they need and engaging them in any workplace change.
Such approaches can tackle physical and psychosocial factors and are empirically likely to be more successful, but the evidence is currently contradictory in terms of return on investment, productivity or health outcomes.

There are key operational factors (leadership engagement, size of investment) that can limit the utility of the approach. Full commitment from senior managers is essential for success and participatory approaches work best in organisations that are less hierarchical, have good labour relations, a tradition of consultatory processes, good communication channels and job design which emphasises personal control when adequate resources are allocated and workers are engaged.

2) Enabling work despite MSDs

“Work should be comfortable when we are well and accommodating when we are ill or injured”. Hadler’s words would make a good motto for most employers.

Acknowledging that MSDs are very common and likely to become more so when there are greater numbers of older-aged workers, good employers will “accept” that some workers will be affected at any point in time and that employment practices need to be suitably flexible that productivity can be maximised.

All the evidence points to the importance of keeping people in work, avoiding prolonged sickness absence, by accommodating their needs with simple cheap reasonable adjustments that may include:

  • rotation of tasks;
  • pacing;
  • rest breaks;
  • flexible hours;
  • simple equipment; and (among others)
  • Access to Work support.

Many of these can be accomplished if each employee feels valued and listened to by “management” so that talented, empathetic line management or human resources, with/without support from occupational health can be invaluable.

A review of community and workplace-based interventions to reduce sickness absence and job loss found that no intervention was clearly superior to others, although effort-intensive interventions were less effective than simple ones, and that cost-benefit analyses struggled to show statistically significant net economic benefits.

Palmer et al conclude therefore that expensive interventions should be implemented only with rigorous cost-benefit evaluation planned from the outset and that more research focused on the cost-effectiveness of simple low cost interventions is needed.

What else do we need to know?

The focus on prevention of disability amongst workers has for too long been predominantly on workers and workplaces. Workers with health problems are also patients and, given that there is not widespread provision of occupational health, much of their occupational and non-occupational healthcare is dealt with by the NHS.

However, since its inception, work participation has not been an outcome of note to healthcare providers or commissioners in the NHS. Unfortunately, this lack of focus on work has led to delays in-built in healthcare referral and assessment that can be actively unhelpful in promoting working whilst unwell.

Whilst on the waiting-list for physiotherapy or orthopaedics, employers can be reluctant to encourage the worker to be at work in case of problems with liability insurance. Employees, in turn, are given the impression that they need to be 100% fit before they can return to work.

Much more could be done in healthcare settings to encourage individuals to be proactive about working despite their condition. But this needs underpinning science about what is safe and how to make risk assessments of the risk/benefit of maintaining an individual at work.

Here too, there is a shortfall in evidence and clear lack of appropriate education of healthcare providers.

Challenges of getting the evidence

This is a complex landscape in which employers, workers, trades unions, healthcare providers and healthcare commissioners as well as policy-makers could all effect positive outcomes, particularly if they worked in partnership.

However, each of these stakeholders is subject to different, competing tensions, which in turn create the challenges which need to be overcome.

1) Employers

Clearly, the employer focus has to be on the economic and commercial viability of its business in the current challenging and changing economic environment.

The workforce is usually the employer’s main asset but also its biggest expense. Researchers therefore need to establish what works best and what is most cost-effective for employers to invest in to maintain and improve the workforce’s health and resilience and maximise the organizational productivity.

Employers could assist by developing partnerships with researchers and being willing to share their company data about job loss and sickness absence caused by MSDs alongside data about their investment in health/wellbeing.

2) Policy-makers

Ironically, the Equality Act may have increased the fear of employers about recruiting a person with existing health needs because of making them uncertain about the risk of breaching the Act and its potential cost to their organisation.

Policy-makers could help by providing more support for employers and other initiatives such as the “Disability Confident” programme and considering incentivisation.

Employers need to recognise that the labour market is constricting as the effects of reduced birth rates shrink the pool of young people. On top of this, the effects of Brexit are yet to be understood. Together, these circumstances mean that investment in the existing workforce is judicious and could pay dividends.

It needs to be debated how much narrowing the disability employment gap is the responsibility of employers and how much should be borne and supported more widely by society and through taxation.

3) Workers

A person’s health is ultimately the responsibility of the individual, but environments and education can be used very effectively to support healthy behaviours and discourage unhealthy ones (for example, the impact of banning cigarette smoking in public places has been considerable).

Employers can also consider:

  • provision of healthy food options for staff;
  • provision of access and resources to support physical exercise (for example cycle to work schemes); and
  • other measures that discourage sedentary behaviour.

However, it is important that working–aged adults who are often “sandwiched” between caring for older relatives and caring for children, as well as working, are supported to prioritise their own health.

The workplace is an excellent place to encourage and support healthy behaviours because employees are accustomed to following regulations around health and safety and workplace cultures can be strong influences on “group norms”.

Moreover, there is a lack of awareness amongst the general population of the importance of (good) work to people’s health and wellbeing. Public health bodies should be creating clear messaging on the importance of providing good quality jobs in which individuals are valued and that people take pride in doing, thereby enhancing their own health, social status and financial stability.

4) Healthcare settings

Employers should be more empowered to have higher expectations of healthcare providers in making diagnoses, providing prompt assessment and/or treatment and communicating effectively with the worker (and employer if the worker gives consent) about their capabilities to be at work.

Work participation needs to be made a key outcome of effective healthcare delivery in all settings, but particularly in MSDs and mental health.

Conclusion

MSDs are common and are likely to remain a major issue for employers as the average age of the workforce increases. Most MSDs are compatible with working – provided that support and simple accommodation measures are available.

Employers have an absolute requirement to protect their workers from MSD accidents/injuries where possible, but many of these conditions are not caused specifically by work.

Nevertheless, the symptoms can be aggravated by some aspects of work and, therefore, employers that acknowledge this and tackle it though talented line management and flexibility are likely to see better worker retention, higher job satisfaction and greater productivity.

References
Hadler N M. Coping with arm pain in the workplace. Occupational musculoskeletal disorders. [2nd], 279-320. 1999. Philadelphia, Lippincott, Williams & Wilkins.

OECD (2014), Mental Health and Work: United Kingdom, Paris: OECD Publishing.

Burton K, Kendall N. ABC. Musculoskeletal disorders. BMJ 2014; 348

Smedley J, Trevelyan F, Inskip H, Buckle P, Cooper C, Coggon D. Impact of ergonomic intervention on back pain among nurses. Scand J Work Environ Health. 2003;29(2):117-23.

Burgess-Limerick R. Participatory ergonomics: Evidence and implementation lessons. Appl Ergon. 2018;68:289-293.

Palmer K T, Harris E C, Linaker C, Barker M, Lawrence W, Cooper C, Coggon D. Effectiveness of community- and workplace-based interventions to manage musculoskeletal-related sickness absence and job loss: a systematic review. Rheumatology (Oxford). 2012;51(2):230-42.

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