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Occupational Medicine 2008 58(1):2-4; doi:10.1093/occmed/kqm095
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Editorial

Inflammatory arthritis and work disability: what is the role of occupational medicine?

Musculoskeletal conditions are the leading cause of severe long-term pain and disability in the world, affecting hundreds of millions of people [1]. This has been recognized by the World Health Organization endorsing the Bone and Joint Decade (2000–2010) [2]. One of the major goals of the decade is to reduce the burden and cost of musculoskeletal disorders to individuals, carers and society. As we approach the latter part of the decade, it is appropriate to reflect on the impact of musculoskeletal disease in the work environment.

Generally, when we consider the impact of musculoskeletal problems in the workplace, the focus is on the prevention and management of the disability caused by musculoskeletal pain, most frequently involving the low back or the neck and upper limb. However, there is another very significant musculoskeletal health problem less well appreciated by occupational physicians, namely, the burden of work disability caused by inflammatory arthritis.

Inflammatory arthritis is common and the subsequent work disability caused by this group of illnesses is significant. For example, rheumatoid arthritis (RA) affects ~1% of the population, and although its prevalence increases with age, its peak age of onset is still well within working age. The estimated work disability from RA varies greatly, but in most studies ~20 to 70% of people who were employed at RA onset are work disabled after 7–10 years [3]. In addition, approximately two-thirds of people with RA who are employed have experienced work loss as a result of their disease in the previous 12 months. Although less well studied, some evidence exists for significant rates of work disability in ankylosing spondylitis [4], psoriatic arthritis [5] and systemic lupus erythematosus [6] as well as less common conditions such as systemic sclerosis and vasculitis [5]. As a consequence of the work disability, the economic impact on patients and their families is very significant [7,8]. Indeed, the work disability associated with inflammatory arthritis accounts for the majority of the costs associated with these conditions [9].

Why is this important for occupational physicians? The nexus between work and health has traditionally been the domain of occupational physicians. We are good at identifying and managing work-related musculoskeletal injury and disability. We are reasonably familiar with making determinations of work relatedness in the context of musculoskeletal co-morbidities (usually osteoarthritis), but we are much less familiar with assessing, managing and minimizing disability associated with pre-existing or developing musculoskeletal disease. Perhaps this is because our focus has often been on individuals already in employment, and many sufferers from arthritis have already been excluded from the workforce by the development of their disease. It is in our own interest and in the interest of our patients and community to develop our skills in this area.

There is a considerable body of literature emerging on the topic, although the number of papers in the occupational medicine literature is still small. So what does the data tell us about minimizing work disability in inflammatory arthritis? There are several practical take home messages that are useful.

(i) People with a higher level of education tend to do better with respect to work disability than those with a lower level education [10]. This finding is consistent across a large number of studies and is of particular relevance for younger patients embarking on working careers. Higher levels of education allow more flexibility in the workforce and may allow people to work in less physically demanding work. Both of these factors appear to be important in maintaining employment in the context of inflammatory arthritis. The advice therefore to people wanting to stay at work is clear—in general, the higher the level of training and education, the better.
(ii) The work disability associated with inflammatory arthritis starts early in the disease. Indeed in the majority of the studies, it appears that a disproportionate amount of the disability occurs in the early years of the disease, with ~30 to 40% of people with RA employed at the commencement of their disease becoming work disabled at 5 years [11] and 20–30% permanently disabled at 2–3 years [12]. If, as some suggest, newer therapies can achieve early remission of the disease (at least in RA), then perhaps we can help a significant proportion of RA sufferers through a critical phase of their disease without loss of employment, thereby avoiding this outcome in the longer term.
(iii) Workplace changes may play a role in minimizing work disability from arthritis. Again this is in the ‘traditional’ realm of occupational medicine practice. Unfortunately few studies to date have tested this hypothesis [13], but surveys of patients with RA have suggested a number of practical approaches which may be of assistance in minimizing work disability [14]. These approaches include suggestions on such things as work organization [15] (start time, shift work, work pace), physical work environments (warmth, soft flooring, minimizing stairs, ergonomic adjustments to work stations) and psychosocial factors (supportive employers and co-workers) [16]. Attention to workplace factors may have additional advantages in that it may help manage some of the less well-recognized features of the disease such as fatigue and psychological distress. This may in turn reduce work absence and disability [17].
(iv) Reducing long-term joint and soft tissue damage may play a role in minimizing work disability. There is a close association between disease severity and work disability [18] and therefore minimizing the long-term impact of the damage inflicted by these conditions appears to be a sensible approach to minimizing work disability. Again, there are few prospective studies that examine this hypothesis. However, in this era of early and aggressive management of inflammatory diseases and with the advent of biological agents such as tumour necrosis factor-alpha blockers, the outlook for this approach is more optimistic [19,20]. Although perhaps not the direct responsibility of most occupational physicians, the improved management of patients with these treatments will certainly see considerable numbers of people in the workplace on these medications. This is yet another reason for occupational physicians to take an interest in this area. These potent immunosuppressants have implications for people in certain work environments such as isolated work sites or situations where the risk of infection is greater.
(v) Work disability is emerging as an important domain to be considered in the performance of longitudinal observational studies in rheumatology [21]. This is in part because of the increasing recognition of the indirect cost burden associated with these conditions and also in part because of the increasing need for pharmacoeconomic evaluations of new and expensive anti-rheumatic drugs [22,23]. This focus on minimizing work disability is likely to become more important with the expected increase in the number and types of biologic agents and increasing competition from pharmaceutical companies for market share.

Work disability from inflammatory arthritis is an important topic for occupational physicians to be familiar with. Occupational physicians, with their unique familiarity of the workplace, are in an ideal position to make a significant contribution in this field. On an individual level, they may be in a position to identify early cases of inflammatory disease and refer them for urgent and aggressive therapy. They may be in a position to counsel workers concerning strategies (such as education) to avoid work disability. They can help create workplace change to assist individuals with arthritis to stay at work. They are also in an ideal position to undertake research as to which changes are most effective in maintaining people at work. Finally, they can identify, monitor and prevent potential complications from the use of disease modifying anti-rheumatic drugs and the newer biological agents in their own workplaces. This area represents an opportunity for occupational physicians to assist the community with cost savings and workforce issues. Most importantly it is another role for occupational physicians to assist our patients in maintaining healthy and satisfying working lives.

E. Michael Shanahan and Michael Ahern

Flinders Medical Centre and Repatriation Hospital, Flinders University, Adelaide

Division of Medicine, Repatriation General Hospital, Daws Road, Daw Park, SA 5041, Australia. e-mail: michael.shanahan{at}rgh.sa.gov.au Tel: +61(8) 82769666; Fax: +61(8) 82751138

References

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  6. Yelin E, Truin L, Katz P, Yazdany J, Gillis J, Panapalis P. Work dynamics among persons with systemic lupus erythematosus. Arthritis Rheum (2007) 57:56–63.[CrossRef][Web of Science][Medline]

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  8. Wolfe F, Michaud K, Choi HK, Williams R. Household income and earnings losses among 6,396 persons with rheumatoid arthritis. J Rheumatol (2005) 32:1875–1883.[Abstract/Free Full Text]

  9. Yelin E. Work disability in rheumatic diseases. Curr Opin Rheumatol (2007) 19:91–96.[Web of Science][Medline]

  10. De Croon EM, Sluiter JK, Nijssen TF, Dijkmans BA, Lankhorst GJ, Frings-Dresen MH. Predictive factors of work disability in rheumatoid arthritis: a systematic literature review. Ann Rheum Dis (2004) 63:1362–1367.[Abstract/Free Full Text]

  11. Young A, Dixey J, Kulinskaya E, et al. Which patients stop working because of rheumatoid arthritis? Results of five years' follow up in 732 patients from the Early RA Study (ERAS). Ann Rheum Dis (2002) 61:335–340.[Abstract/Free Full Text]

  12. Sokka T. Work disability in early rheumatoid arthritis. Clin Exp Rheumatol (2003) 21(Suppl. 31):S71–S74.[Web of Science][Medline]

  13. Varekamp I, Verbeek JH, van Dijk FJ. How can we help employees with chronic diseases to stay at work? A review of interventions aimed at job retention and based on an empowerment perspective? Int Arch Occup Environ Health (2006) 80:87–97.

  14. Lacaille D, Sheps S, Spinelli JJ, Chalmers A, Esdaile JM. Identification of modifiable work-related factors that influence the risk of work disability in rheumatoid arthritis. Arthritis Care Res (2004) 51:843–852.[CrossRef][Web of Science]

  15. Chorus AMJ, Miedema HS, Wevers CMJ, van der Linden SJ. Work factors and behavioural coping in relation to withdrawal from the labour force in patients with rheumatoid arthritis. Ann Rheum Dis (2001) 60:1025–1032.[Abstract/Free Full Text]

  16. Varekamp I, Haafkens JA, Detaille SI, Tak PP, van Dijk FJ. Preventing work disability among employees with rheumatoid arthritis; what medical professionals can learn from the patients' perspective. Arthritis Rheum (2005) 53:965–972.[CrossRef][Web of Science][Medline]

  17. Mancuso CA, Rincon M, Sayles W, Paget SA. Psychosocial variables and fatigue: a longitudinal study comparing individuals with rheumatoid arthritis and healthy controls. J Rheumatol (2006) 33:1496–1502.[Abstract/Free Full Text]

  18. Sokka T, Pincus T. Markers for work disability in RA. J Rheumatol (2001) 28:1718–1722.[Abstract/Free Full Text]

  19. Kavanaugh A, Antoni C, Mease P, et al. Effect of infliximab therapy on employment, time lost from work, and productivity in patients with psoriatic arthritis. J Rheumatol (2006) 33:2254–2259.[Abstract/Free Full Text]

  20. Yelin E, Trupin L, Katz P, Lubeck D, Rush S, Wanke L. Associations between entanercept use and employment outcomes among patients with rheumatoid arthritis. Arthritis Rheum (2003) 48:3046–3054.[CrossRef][Web of Science][Medline]

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  22. Doan QV, Chiou C-F, Dubois RW. Review of eight pharmacoeconomic studies of the value of biologic DMARDs (Adalimumab, Etanercept, and Infliximab) in the management of rheumatoid arthritis. J Manag Care Pharm (2006) 12:555–569.[Web of Science][Medline]

  23. Strand V. OMERACT II: the biologics perspective. J Rheumatol (1995) 22:1415–1417.[Web of Science][Medline]


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