The importance of work for social participation and quality of life in people with rheumatic diseases

Prof. Dr. Alison Hammond, FCOTProfessor in Rheumatology Rehabilitation

University of Salforda.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 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 2007Quantitative: 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 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 arthritisSupport from family/ co-workers (Lacaille, 2004: survey n = 581)

Supportive managementEffective 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/ barriersWork site assessment

Ergonomic modifications/job accommodationsErgonomic modifications/job accommodationsSupport & communication: individual, employer,Support & communication: individual, employer,

others (eg family, co-workers);others (eg family, co-workers);Self-advocacy skills training; Self-advocacy skills training; Disability awareness trainingDisability awareness training

Condition management (physical, psychological); Condition management (physical, psychological); Medical treatment; Medical treatment;

Staged return to work management by employers.Staged return to work management by employers.

Career exploration / counselling;Career exploration / counselling;Job finding skills training;Job finding skills training;

Job placements/ retrainingJob placements/ retraining. . DWP, 2004; Allaire et al, 2007.

SAW

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 problemso 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 workToo small /short to identify changes in work status

SAW: Rehabilitation servicesJob 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 satisfactionNeed 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 leaveRCT 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 necessaryNegotiated RTW12m: reduction in sick leave: OA = 45.4 days; Inflammatory arthritis = 35.4 daysCost-effective

SAW – early sick leave: disability employment servicesRCT 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 + benefitsRTW: co-operation employee, employer and NIO modified work measuresAt 12m:Sick leave reduced 8 days overallIn RMD sub-group: 68 days

SAW/RTW: MDT interventionsJob retention intervention: (De Buck et al 2005: NL)Mix extended sick leave, employed RCT (n = 140 RA): NLmedical assessment Rheumatologist Occupational health doctor liaisonVocational 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 instabilityo Early stages of sick leaveoConveniently 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 SciencesC407

Allerton BuildingFrederick Road

SalfordM6 6PU

United Kingdoma.hammond@salford.ac.uk