The importance of work for social
participation and quality of life in
people with rheumatic diseases
Prof. Dr. Alison Hammond, FCOT
Professor in Rheumatology Rehabilitation
University of Salford
a.hammond@salford.ac.uk
Introduction
1. The problems faced by people with RMDs
• staying at work (SAW) or
• returning to work (RTW).
2. The effectiveness and benefits of early rehabilitation
to enable SAW or early RTW
3. Future developments to improve work participation
and quality of life for people with RMDs
Work disability and sick leave
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40-45%: rheumatoid arthritis (5 y )
18 –26% ankylosing spondylitis
19-23% systemic lupus
17-33% psoriatic arthritis
34% systemic sclerosis
Sick leave in early RA range = 7-84 days/y
24% of work is impaired (presenteeism)
Newhall-Perry et al 2000; Merkesdal et al 2001; Verstappen et al 2004; Burton et al
2006; Al-Dhahani et al 2009; Baker et al 2009; Wallenius et al 2009; Vliet Vlieland et al
2009; Ariza-Ariza et al 2009; Rohekar & Pope 2010; Zhang et al 2010)
Physical, work and knowledge
barriers
 Fatigue (esp. RA)
 Pain;
 Physical limitations: hand function (eg using a computer/
writing), moving quickly, standing, lifting, bending, higher
work speed)
 Work-life balance: reduced leisure activities/ADL
 Low job autonomy
 Unadapted work environments, transport difficulties
 Asking for and obtaining ergonomic modifications/ job
accommodations (lack of knowledge and/ or advocacy skills)
Qualitative: Mancuso 2000; Backman 2004; Allaire 2007; Lacaille 2007
Quantitative: Proctor et al, 2000; Allaire et al, 2001 ; Teasell et al, 2001; De Buck et al, 2002; Tubach et al,
2002; Verstappen et al, 2004; Lacaille et al, 2004; Yelin, 2004; Manek et al, 2005; Eberhardt et al, 2007.
Psychosocial barriers
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Unwilling to disclose arthritis
Reluctance & emotional barriers
Increasing role overload
Dealing with others responses
Guilt
Future worries: employment and finances
Higher perceived job strain
Loss of work self-efficacy
Qualitative: Gignac 2006; Lacaille, 2007; Allaire 2007
Quantitative: Proctor et al, 2000; Allaire et al, 2001 ; Teasell et al, 2001; De Buck et al,
2002; Tubach et al, 2002; Verstappen et al, 2004; Lacaille et al, 2004; Yelin, 2004; Manek
et al, 2005; Eberhardt et al, 2007.
Increasing risk…
 extended periods of sick leave
 longer duration of unemployment.
 Survey: n =300; RA 4 y.
 56% work disabled
 only 18% of these willing to work again
(Verstappen et al, 2005)
References for predictive factors:
Proctor et al, 2000; Allaire et al, 2001 ; Teasell et al, 2001; De Buck et al, 2002; Tubach et al, 2002; Verstappen et al,
2004; Lacaille et al, 2004; Yelin, 2004; Manek et al, 2005; Eberhardt et al, 2007.
Reducing risk…
Ergonomic modifications to workplace:
 2.5 x less likely to stop work
 Greater use of coping strategies (physical /
psychological) to self manage arthritis
 Support from family/ co-workers
(Lacaille, 2004: survey n = 581)
 Supportive management
 Effective communication : need for job
accommodations and how to change
work habits
(Shaw et al, 2007)
Vocational Rehabilitation
“A process to overcome the barriers an
individual faces when accessing, remaining or
returning to work following injury, illness or
impairment.”
(DWP, 2004)
Assessment of needs/ barriers
Work site assessment
SAW
Ergonomic modifications/job accommodations
Support & communication: individual, employer,
others (eg family, co-workers);
Self-advocacy skills training;
Disability awareness training
Condition management (physical, psychological);
Medical treatment;
Staged return to work management by employers.
DWP, 2004;
Allaire et al, 2007.
Career exploration / counselling;
Job finding skills training;
Job placements/ retraining.
RTW
Ergonomic modifications…
Mini keyboard: half size keys require less effort
Built in touch pad to reduce arm movement
Voice activated software
Ergonomic chair
Flex Desk
Battery operated hand
held letter opener
Evidence for early work
rehabilitation
SAW: Rehabilitation services
Job retention intervention: (Macedo et al 2007: UK):
o RCT (n=28);
o employed RA
o usual care v
o comprehensive Occupational Therapy for functional,
psychological and hand problems
o work site assessment, ergonomic modifications, disability
rights advice
o liaison employer, Access to Work (work adaptations)
6m: Significant reduction work instability, improved work
satisfaction, pain, disability;
 No differences days missed work
 Too small /short to identify changes in work status
SAW: Rehabilitation services
Job retention intervention (Allaire et al 2003: USA):
 All employed (not on sick leave, “concerns re SAW”)
 RCT (n = 242; 58% RA; OA, SLE, PA, AS); average HAQ 0.54.
 VR counsellor 2x 1.5 hrs; Optional work visit and employer
liaison.
 Structured interview needs/ barriers; computing, travel,
access, work hours; psychological aspects; job
accommodation plan. Disability rights; disclosing and
requesting job accommodations. Career advice.
 3.5 yrs: 49% fewer job losses; high levels satisfaction
 Need for convenient services or clients delay accessing
service
SAW early sick leave: MDT interventions
Job retention intervention (Abasolo et al 2005, 2007: Spain)
 Patients with RMDs/MSDs on sick leave
 RCT n = n=13,077; (inflammatory: n = 187; OA n=258)
Intervention:
 Level 1: Medical assessment; drug management; condition education;
self-management education (avoid rest, exercise, ergonomic care,
increase physical activity)
 Level 2: (no improvement 2-6w): referral to rehabilitation, further
investigations as necessary
 Negotiated RTW
12m: reduction in sick leave:
 OA = 45.4 days; Inflammatory arthritis = 35.4 days
 Cost-effective
SAW – early sick leave: disability
employment services
RCT postal information on RTW support available (Fleten et al,
2006: Norway)
 n= 990 (inc. n=99 with RMDs)
 Letter 2w+ sick leave: brief information work measure
available:
 RTW adjusted job + benefits
 RTW: co-operation employee, employer and NIO modified
work measures
At 12m:
 Sick leave reduced 8 days overall
 In RMD sub-group: 68 days
SAW/RTW: MDT interventions
Job retention intervention: (De Buck et al 2005: NL)
 Mix extended sick leave, employed
 RCT (n = 140 RA): NL
 medical assessment Rheumatologist
 Occupational health doctor liaison
 Vocational assessment and advice (finances, job
accommodations)
 Rehab: OT, PT, counselling as appropriate
 Average 6 hours contact.
No difference in job retention/ RTW at 2 years.
 Improved mental health, less fatigue
 ?? Due to 40% already on extended sick leave – too late?
 Good disability benefits system in NL
Summary of studies
1. Early intervention more effective:
o In work: with work instability
o Early stages of sick leave
o Conveniently timed and located
2. Longer delay, more difficult to SAW/RTW.
3. VR and MDT interventions effective.
What more can be done?
1. In work:
Brief interventions :
 Early screening: risk of work instability.
Enable:
 Work self-management education: exercise, pacing,
ergonomic modifications to work tasks),
 Work assessment & advice: simple work and environment
modifications (equipment, flexible hours, adaptations, access)
 Employment rights education
 Open communication employee and employer
What more can be done?
2. Early sick leave:
 Advice and intervention early (eg by 2 weeks)
 Assess for needs
Stepped care:
 Medical management (eg drug therapy)
 Condition and self-management education, work assessment
and advice
 Work rehabilitation and therapy (Occupational therapy,
physiotherapy, cognitive-behavioural therapy) as necessary
Future research
 RCTs: Do effective interventions developed in the USA, Spain
and Norway, reduce sick leave and improve job retention in
other countries with different socioeconomic conditions and
employment benefits/ regulations/law?
 What is their impact on health, participation, quality of work
and quality of life?
 Observational studies and RCTs: effectiveness of current VR
services?
 Are they cost-effective?
 What are the most effective ways of delivering interventions
in practice?
Thank you
Please Contact
Prof. Dr Alison Hammond,
Professor in Rheumatology Rehabilitation, University of Salford
School of Health, Sport and Rehabilitation Sciences
C407
Allerton Building
Frederick Road
Salford
M6 6PU
United Kingdom
a.hammond@salford.ac.uk