Occupational health advisers have an important role in managing osteoarthritis in the workplace. Ambra Pizzarelli and Professor Anne Harriss discuss the impact of the illness on the individual’s work and how to manage the condition.
Work is an integral part of modern life and, to some extent, it contributes to a person’s identity, not only by bringing economic benefits but also by allowing individuals to find their place in society and to give them a meaningful purpose.
There is a strong link between work and health (Waddell and Burton, 2006; Palmer et al, 2013). Several studies (Sandy et al, 2008; Roni et al, 2012) have underlined the positive effects of employment on the wellbeing of individuals, their families and, in turn, on their communities and these benefits are not only at an economic level, but they also stretch to a social level.
An independent review commissioned by the Department for Work and Pensions (2008) of the evidence on the relationship between work, health and wellbeing found that work plays a pivotal role in individual identity and social role, and, alongside socio-economic status, it is the main component of the social gradient in physical and mental health. Being in “good” employment is protective of health (Waddell and Burton, 2006; Marmot, 2010). Conversely, worklessness and poor health are closely linked together (Adams et al, 2003).
Life expectancy has increased and as a society we are working longer. As a consequence of an ageing workforce, the burden of chronic health conditions must be taken into account.
Chronic health conditions have a negative impact on the employability of workers. Furthermore, a comparative study between workers with and without chronic health conditions concludes that those suffering with a chronic health condition experience more problems due to ageing and more barriers to perform job tasks (Koolhaas et al, 2012).
The OH practitioner must be aware of these factors when assessing an individual’s fitness-to-work performance. This article examines the reciprocal effects of osteoarthritis of the knee, a degenerative musculoskeletal condition of an individual and the impact this debilitative illness has on their work.
Osteoarthritis (OA) is the most common joint disease in the world and it is estimated it affects 10% of men and 18% of women over 60 years of age (Glys-Jones et al, 2015).
In 2013, 7.3 million people sought treatment for OA in England, equal to 33% of the population over 45 years old.
The knee is the most common site for OA and, in particular, the same research shows that 4.11 million people have OA of the knee in England and this number is expected to grow.
According to Arthritis Research UK (2013), the number of people with OA of the knee is estimated to increase to 8.3 million by 2035 (allowing for the size and ageing of the population and increasing levels of obesity).
There is a general consensus that human functional capacities change with age and physical capacity starts to decline at a quicker rate in comparison to mental or social capacities (Chan et al, 2011).
Traditionally, OA has been viewed as a disease resulting from merely mechanical cartilage degradation and has been perceived as a “natural” part of the ageing process with limited possibility of intervention and subsequent rehabilitation, however this has been challenged in recent years (Dziedzic et al, 2014).
A deeper understanding of the aetiology of OA has contributed to a shift in attitudes towards this debilitating condition, with implications for the workplace due to its impact on both daily living and the ability to undertake work tasks.
This has been acknowledged by the National Institute for Health and Care Excellence (NICE) and incorporated in the OA care and management guidelines (2014).
The pathogenesis of osteoarthritis is complex and develops as a result of mechanical, cellular and biochemical events (Hunter, 2011).
Degenerative joint disease and osteoarthrosis are interchangeable terms for OA. Interestingly, the term osteoarthrosis emphasises the degenerative aspect of the disorder, while OA underlines the inflammatory component.
Risk factors associated with the development of the disease are varied and include obesity, advancing age, being female and genetic changes (Sinusas, 2012).
OA can develop in any joint, however commonly affected areas are knee, hip, hand, spine and foot. Six million people in the UK suffer with OA of the knee (Dulay, 2015), a figure that illustrates how widespread and common the problem is.
Cooper and Palmer (2010) cite Cooper and others (1994) highlighting that the most significant non-occupational risk factors for OA in the knee include obesity, knee injury, menisectomy and Heberden’s nodes.
They go on to note that occupationally, the risk of developing OA of the knee is associated with work tasks involving squatting, kneeling, prolonged and repetitive bending of the knee and load bearing while the knee is flexed. Occupations such as carpet laying come to mind as all these actions are included within their job tasks.
The most common symptoms of OA include joint pain, stiffness coupled with movement limitation and restriction (Dulay, 2015); they are a consequence of the pathophysiology process of the disease that affects the joint cartilage and surrounding tissues. When a joint develops OA, some of the cartilage covering the bones, typically at the point of maximum load bearing, degenerates. This process triggers a cascade of events (illustrated in the picture on p.27) that include:
- Formation of osteophytes (abnormal outgrowth of cartilage that becomes ossified).
- Thickening of the synovium (the inner layer of the joint capsules that produces synovial fluid).
- Thickening and contraction of capsule and ligaments.
Signs, symptoms and diagnosis
Pain and stiffness are the main symptoms of OA, with pain being the primary reason patients consult their GP. Cox (2009) cited in Walker (2011) suggests that pain associated with OA is generally described as dull, aching or throbbing and confined to a specific region.
The pain appears to worsen with activity, especially following a period of rest (Sinusas, 2012). This has been described as the gelling phenomenon. This stiffness normally lasts less than 15-30 minutes, unlike stiffness associated with inflammatory disease such as rheumatoid arthritis, which lasts for 45 minutes or more (Manek et al, 2000).
Walker (2011) lists among the clinical features:
- crepitus – a grinding feeling on moving the joint, due to the rough articular joint surfaces;
- reduced range of movements;
- pain on movement;
- mild synovitis; and
- the diagnosis of OA is made on clinical and radiological grounds. X-rays are helpful to differentiate diagnosis and in case surgical interventions are being contemplated.
NICE (2014) encourages a holistic approach to an OA assessment and management to enhance understanding of the condition and counter misconceptions.
Self-management strategies agreed with the individual offer a greater feeling of self-empowerment and also decrease reliance on health services and pharmacological interventions (Corben and Rosen, 2005).
As underlined by Hunter (2011), the suggested interventions for pain management in OA should include non-pharmacological intervention first, including general health and lifestyle advice, then a range of painkillers and, finally, the surgical route. However, it has been highlighted that the first step is very often neglected and this is to the patient’s detriment (Glazier et al, 1998, cited in Hunter, 2011).
Paracetamol followed by non-steroidal, anti-inflammatory drugs, such as ibuprofen, are the most popular choice of analgesia.
The pain associated with OA is due to chemical mediators released into the joint triggered by inflammation processes to an extent where joint movements that in normal circumstances would be innocuous now cause a painful response.
This concept is described by the term allodynia, which is the sensation of pain caused by something, such as walking or kneeling, that would not normally cause pain.
The drug hydroxychloroquine is commonly used to treat inflammatory arthritis, such as rheumatoid arthritis. The effectiveness of this drug in alleviating the symptoms of OA has been called into question, however research studies (Kingsbury et al, 2013) suggest that as inflammation is also present in OA, hydroxychloroquine can make a positive contribution to the relief of pain symptoms.
Assessment of fitness for work
Occupational health practitioners assessing fitness to work must remain mindful of an increasingly ageing workforce and the issues associated with this and, as underlined by Chan et al (2000), work ability encompasses an interaction of social, environmental and individual factors including physical fitness, coping skills, social support network and health behaviour.
These elements have also emerged in a study carried out by Haugli et al (2011) aimed at identifying what facilitates a successful return to work.
Participants taking part in the study three years after a return to work underlined that successful outcomes were achieved by the concomitant presence of support from the surroundings (for example, from managers), positive encounters with health professionals and by achieving an increased sense of self-understanding of own identity, values and resources.
It is estimated that by 2050, 30% of the population in Europe will be more than 65 years of age (Palmer, 2012). A recent American study (SunAmerica Retirement study, 2015) found that the majority of people approaching retirement age did not want to retire.
For some, this may be due to the impact of poverty and a need to continue to be earning, but for the majority of respondents there was a willingness to remain active contributors to society.
This may be the case for those approaching retirement age in the UK as the Government has raised the state pension age and consequently there will be older people still at work (Department for Work and Pensions, 2008). People may choose to work longer, in a full or part-time capacity because of their financial or personal circumstances.
Palmer et al (2013) suggest that the main objective of a fitness-to-work assessment is to assess the individual’s capability to undertake their job role effectively without posing any risks to their health and safety or that of others.
In order to provide a fair but rigorous assessment it is helpful to use a framework such as the Murugiah et al (2002) fitness-for-work model. This incorporates four main elements: consideration of personal aspects; work characteristics; the working environment; and legal aspects.
A review study carried out by Palmer (2012), which focused on workers with OA of the knee, reflected on the need to ask some questions when assessing whether work for people in pain and with mobility problems represents the best and safest option. It suggests that the practitioner should consider the following:
- the extent to which OA of the knee limits work participation and causes sickness absence and health related job loss; and
- evidence that interventions promote work participation in patients with knee OA.
Stubbs et al (2015) have underlined that one-fifth of people suffering with OA experience symptoms of depression and anxiety. This has been linked to the level of physical disability experienced by sufferers leading to social isolation. When assessing a client with severe OA, it may be pertinent for the practitioner to undertake an assessment of depression and anxiety using appropriate tools, such as PHQ-9 or GAD-7 questionnaires.
Palmer et al (2013) underline that the cost of OA to employers is set to rise as the age of retirement and the prevalence of obesity in the population are on the increase in the western world.
The Department for Work and Pensions (cited in Palmer, 2013) has estimated that, annually in the UK, OA costs £3.2 billion in productivity and encouraging work that keeps the individual active and encourages flexibility of the affected joints is likely to be of benefit.
The work of Page et al (2011) indicates that physiotherapy interventions can reduce pain and improve function in people suffering with knee OA and effective treatment supports them to stay at work.
In relation to the work characteristics, and in view of physical symptoms, a range of workplace adjustments may be appropriate:
- employees taking breaks at regular intervals;
- a phased return to work to build up the employee’s strength, building up from part time to full time over an agreed period of time following a period of significant of sickness absence;
- modified duties where necessary;
- taking regular postural breaks, for example, after every 20-30 minutes of standing, complete another task requiring sitting or walking for two to three minutes;
- considering the use of anti-fatigue matting (if standing for a prolonged period of time in the same area) and specialised inner soles;
- education in the use of correct manual handling techniques; and
- time off during working hours in order to allow employees to attend rehabilitation assessment or treatment appointments.
For those staff who are employed in posts with job tasks that could exacerbate their condition, the completion of a risk assessment with the employee in line with Regulation 3 of the Management of Health and Safety at Work Regulations (1999) and the Health and Safety Act at Work etc. Act (1974) will ensure the worker is able to undertake their job requirements.
The employer has a duty of care under the Health and Safety at Work etc Act to ensure the health, safety and wellbeing of employees at work and has a responsibility to reduce potential risks to their health once the risk assessment has been carried out.
Healthy eating and taking part in physical exercise are important considerations.
Supporting a return to work
The role of the OH practitioner is to suggest recommendations to support employees with long-term conditions such as OA to stay in work.
A sound understanding of the pathophysiology of osteoarthritis is essential in order to offer appropriate advice, particularly when considering fitness for work or when providing advice to managers within a process of vocational rehabilitation.
Traditionally, rehabilitation has been focused on the treatment of disease and pain reduction, but in recent times there has been an increased focus on a biopsychosocial approach, looking at the individual, workplace social and economic factors (Haugli et al, 2011).
In conclusion, general health advice, such as maintaining a healthy weight, integrating low-impact physical activities like swimming, and developing an effective return-to-work programme, will lead to a successful outcome for both employee and employer.
The process should be designed to facilitate reintegration to work and making long-term changes to the worker’s physical health.
This may be achieved by a multidisciplinary approach, including the OH service, collaborative working with other healthcare practitioners, including the client’s GP and physiotherapist, and liaison with line management.
Ambra Pizzarelli RGN, RM, PgDip Health Promotion is OH adviser and final-year student BSc(Hons) in OH nursing. Anne Harriss MSc, BEd, RGN, RSCPHN, OHNC,NTFHEA, PFHEA, CMIOSH, QN, FRCN is professor of occupational health, London South Bank University.
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