Workplace barriers among people with rheumatic and chronic back pain: Results from the work experience survey for rheumatic conditions.

BACKGROUND: The Work Experience Survey for Rheumatic Conditions (WES-RC) is a prominent feature of an evidence-based intervention to prevent premature job loss among people with arthritis. The WES-RC is used to identify client perceived barriers related to work performance. The degree to which people with arthritis and rheumatic conditions report barriers on the WES-RC has not been reported. OBJECTIVE: The purpose of this study was to characterize the barriers reported on the WES-RC. METHODS: Data from participants who completed the WES-RC in the "Work-It" study trial were included (N = 143). Descriptive statistics were used to characterize the sample and the frequency with which barriers on the WES-RC were reported. Responses to the top three bothersome barriers to study participants were summed. RESULTS: The mean age of the sample was 50.3 years; 73% were female, and 66% white. All WES-RC items were checked as a barrier by at least two participants; less than 10 participants checked 34 items. Barriers in the 'getting ready for work and traveling to and from, or for work' domain, were frequently reported. The most bothersome barriers were 'standing or being on feet too long' and 'prolonged sitting'. CONCLUSION: The WES-RC is a self-reported checklist that captures a wide breadth of work-related barriers that could be experienced by people with arthritis who are currently employed.

Decrease in sick leave among patients with rheumatoid arthritis in the first 12 months after start of treatment with tumour necrosis factor antagonists: a population-based controlled cohort study.

OBJECTIVE: To investigate the effect of tumour necrosis factor (TNF) antagonist treatment of patients with rheumatoid arthritis (RA) on sick leave (SL) and disability pension (DP) in a population-based setting in southern Sweden. METHODS: All patients with RA in the South Swedish Arthritis Treatment Group register living in the county of Skåne (population 1.2 million), who started their first treatment with a TNF antagonist between January 2004 and December 2007 and were 18-58 years at treatment start (n = 365), were identified. For each patient with RA, four matched reference subjects from the general population were randomly selected. Data were linked to the Swedish Social Insurance Agency register and the point prevalence of SL and DP as well as days of SL and DP per month were calculated from 360 days before until 360 days after treatment start. RESULTS: At treatment start 38.6% of the patients with RA were registered for SL. During the first 6 months this share dropped to 28.5% (decrease by 26.2%, p< 0.001). This level remained stable throughout the first treatment year. Comparing patients with RA to the reference group the relative risk of being on SL was 6.6 (95% CI 5.2 to 8.5) at initiation of anti-TNF treatment and 5.2 (95% CI 4.0 to 6.8) 1 year after that. The corresponding figures for DP were 3.4 (95% CI 2.7 to 4.2) and 3.2 (95% CI 2.7 to 3.9). CONCLUSIONS: There was a marked decline in SL during the first 6 months of TNF antagonist treatment in patients with RA in southern Sweden, maintained throughout the first year, which was not offset by a corresponding increase in DP.

Efficacy of a Work Disability Prevention Program for People with Rheumatic and Musculoskeletal Conditions: A Single-Blind Parallel-Arm Randomized Controlled Trial.

OBJECTIVE: Work disability rates are high among people with rheumatic and musculoskeletal conditions. Effective disability preventive programs are needed. We examined the efficacy of a modified vocational rehabilitation approach delivered by trained occupational therapists and physical therapists on work limitation and work loss over 2 years among people with rheumatic and musculoskeletal conditions. METHODS: Eligibility criteria for this single-blind, parallel-arm randomized trial included ages 21-65 years, 15 or more hours/week employment, a self-reported doctor-diagnosed rheumatic or musculoskeletal condition, and concern about staying employed. The intervention consisted of a 1.5-hour meeting, an action plan, written materials on employment supports, and telephone calls at 3 weeks and 3 months. Control group participants received the written materials. The primary outcome was the Work Limitations Questionnaire (WLQ) output job demand subscale. The secondary outcome was work loss. Intent-to-treat analyses were performed. RESULTS: Between October 2011 and January 2014, 652 individuals were assessed for eligibility. A total of 287 participants were randomized: 143 intervention and 144 control participants. In total, 264 participants (92%) completed 2-year data collection. There was no difference in the mean ± SD WLQ change scores from baseline to 2-year followup (-8.6 ± 1.9 intervention versus -8.3 ± 2.2 control; P = 0.93). Of the 36 participants who experienced permanent work loss at 2 years, 11 (8%) were intervention participants and 25 (18%) control participants (P = 0.03). CONCLUSION: The intervention did not have an effect on work limitations but reduced work loss. The intervention can be delivered by trained rehabilitation therapists.

Workplace barriers encountered by employed persons with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is an auto-immune connective tissue disease characterized by fibrosis of skin, blood vessels, and internal organs that results in significant disability. OBJECTIVE: To identify the work barriers faced by people with systemic sclerosis (SSc) in maintaining employment. METHODS: Thirty-six people with SSc who were working more than 8 hours per week completed the Work Experience Survey, which contains lists of potential work barriers, including the ability to travel to and from work; get around at work; perform essential job functions, including physical, cognitive, and task-related activities; work with others; and manage work conditions. RESULTS: Thirty-three participants completed and returned the questionnaires, most of whom were female, and working full time and in professional careers. Principal disease symptoms included fatigue, Raynaud's phenomenon, esophageal involvement, and leg or hand/wrist pain. All participants reported some barriers with a mean of 18 barriers per participant. At least three quarters of participants cited outside temperature (82%), cold temperatures inside the workplace (76%), and household work (76%), as barriers. The next most common barriers were using both hands (64%), arranging and taking part in social activities (64%), being able to provide self-care (61%) and working 8 hours (58%). CONCLUSION: Participants reported a wide range of barriers, from cold temperatures, to physical job, fatigue related, and non-workplace demands, in maintaining the worker role. The barriers reflect the disease symptoms they reported. Identifying workplace barriers facilitates the creation of job accommodations or adaptations that will allow people with SSc to continue working.

The Work-It Study for people with arthritis: Study protocol and baseline sample characteristics.

BACKGROUND: People with arthritis are at risk of work disability. Job accommodation and educational programs delivered before imminent work loss can minimize work disability, yet are not currently being widely implemented. The Work-It Study is a randomized controlled trial testing the efficacy of a problem solving program delivered by physical and occupational therapy practitioners to prevent work loss over a two-year period among people with arthritis and rheumatological conditions. OBJECTIVE: The purpose of this paper is to describe the protocol of the randomized controlled trial, and describe the baseline characteristics of the subjects and their work outcomes. METHODS: 287 participants were recruited from the Boston area in Massachusetts, USA. Eligible participants were aged between 21-65, self-reported a physicians' diagnosis of arthritis, rheumatic condition, or chronic back pain, reported a concern about working now or in the near future due to your health, worked at least 15 hours a week, had plans to continue working, and worked or lived in Massachusetts. Subjects were recruited through community sources and rheumatology offices. Participants in the experimental group received a structured interview and an education and resource packet, while participants in the control received the resource packet only. The baseline characteristics and work related outcomes of the participants were analyzed. CONCLUSIONS: To our knowledge, the Work-It Study is the largest and most diverse randomized controlled trial to date aiming to identify and problem solve work-related barriers, promote advocacy, and foster work disability knowledge among people with chronic disabling musculoskeletal conditions. Despite advances in medical management of arthritis and other rheumatological and musculoskeletal conditions, many people still have concerns about their ability to remain employed and are seeking strategies to help them sustain employment.

Work disability resulting from chronic health conditions.

OBJECTIVES: To describe current programs and policies for addressing work disability among adults with chronic health conditions, and to identify opportunities for new research aimed at reducing the problem. METHODS: The authors conducted secondary data analysis and a literature review. RESULTS: Millions of Americans with a chronic health condition have a work disability or are at risk of developing one. This public health problem is costing hundreds of billions of dollars a year nationally in lost productivity and diminishing the quality of life of millions of Americans. The medical care system, employers, and government--three traditional sources of help for adults with chronic health problems--are not sufficiently oriented toward the primary or secondary prevention of work disability. CONCLUSIONS: New research is urgently needed to reduce the burden of work disability on individuals and society.

Experiencing work as a daily challenge: the case of scleroderma.

OBJECTIVE: Little is known about the physical and discretionary aspects of work that people with scleroderma (SSc) find difficult. This article describes the findings from a study that explored the challenges and adaptations made by individuals with SSc to continue to work. PARTICIPANTS: Thirty-two employed individuals with SSc participated. Participants were predominantly women (82%), white (79%), and well educated (M = 16.9 years). The average age was 47.3 years, and 60.6% were married. Mean disease duration was 9.7 years, and 56.2% had diffuse SSc. Mean years on the job was 10.2 (SD ± 8.8), and 71.9% worked at least 35 hours per week. METHODS: Participants engaged in a single structured interview about work-related challenges and adaptations. Content and thematic analysis was used to identify key themes across the interviews. RESULTS: Employees with SSc experienced Work as a daily challenge. This central theme described the general work experience for most participants. Three subthemes described their specific experiences: The work environment: Opportunities, challenges, and accommodations; Career planning; and Supportive others. CONCLUSIONS: The participants were anxious to find scenarios that allowed them to continue to work. Worksite accommodations and flexibility in scheduling can make the difference between working and disability.

Ergonomic intervention for employed persons with rheumatic conditions.

Prior articles in this series on employment and arthritis have documented the major impact arthritis and other rheumatic conditions have on employment. As expected, physically demanding job tasks, including hand use, are substantial risk factors for work limitation. Computer use has been increasing. People with arthritis may choose occupations involving extensive computer use to avoid occupations with other physical demands. But studies show many people with arthritis conditions have difficulty using computers.Ergonomic assessment and implementation helps relieve the physical and other demands of jobs. The Ergonomic Assessment Tool for Arthritis (EATA) is specifically for people with arthritis conditions. Since the EATA can be conducted off worksite, it is feasible to use with workers not wishing to disclose their condition to their employer. Available research supports the effectiveness of ergonomic intervention as a viable method to reduce work limitation for persons with arthritis. Some workers will need additional vocational intervention to remain employed long term. However, ergonomic intervention is a useful first step, as it promotes awareness of arthritis effects on work activities. Assisting workers with arthritis or other rheumatic conditions to use ergonomics to enhance their ability to work well should be an important aspect of managing these conditions.

Development of a structured interview tool to help patients identify and solve rheumatic condition-related work barriers.

OBJECTIVE: To develop a comprehensive and efficient assessment tool for rheumatic condition-related work barriers and explore its use by physical and occupational therapists. METHODS: Literature on arthritis work barriers was examined, followed by the collection of qualitative data on work barriers from patients with rheumatic conditions. A tool called the Work Experience Survey-Rheumatic Conditions (WES-RC), which identifies barriers and facilitates the formation of solutions for barriers, was developed using this data. Ten physical and occupational therapists reviewed the initial version of the tool and provided qualitative data and the relevance of its use by therapists. Using this data, the WES-RC was revised. The therapists then administered the WES-RC to 20 patients. Quantitative data, qualitative data, and results of the administrative experience were collected from therapists after each administration. Relevant data were used to further revise the WES-RC. Qualitative data were coded and themes developed by 2 readers and compared. Means and frequencies were used to describe the quantitative data. RESULTS: The WES-RC addressed patients' work barriers quite well with a mean score of 8.7, on a scale of 1-10 where 10 = barriers completely covered, and administration time was reported as "about right" in 18 (90%) of 20 administrations. Eighty percent of the therapists' administration experiences were positive. Therapists reported barrier identification as easy, while solution formation was difficult in 45% of the administrations and judged insufficient in 35%. CONCLUSION: The WES-RC appears to be feasible for rheumatology patients and for use by physical and occupational therapists. Further study is needed to enhance effective solution formation.

Current risk factors for work disability associated with rheumatoid arthritis: recent data from a US national cohort.

OBJECTIVE: To explore, using recent data, whether and how risk factors for rheumatoid arthritis (RA) work disability may differ from previous studies. METHODS: Subjects were 953 individuals with RA from a US cohort who provided data semiannually over 18 months (years 2002-2005). A nested case-control design was used with matching on time of baseline data collection. All subjects were employed at baseline; cases were consistently not employed at followup, whereas controls remained employed. Hierarchical conditional logistic regression assessed the roles of demographic, RA disease, general health, and work factors as predictors of work disability. Recursive partitioning and causal modeling procedures were also used. RESULTS: Sample characteristics were mean age 51 years, 82% female, and 92% white. Older age (odds ratio [OR] 1.2, 95% confidence interval [95% CI] 1.1-1.4) and lower income (OR 1.7, 95% CI 1.0-2.7) predicted work disability, whereas more hours worked (OR 0.9, 95% CI 0.8-0.9) and preference to work full time (OR 0.2, 95% CI 0.1-0.4) or part time (OR 0.4, 95% CI 0.2-0.6) versus not to work were protective in the regression analysis. In recursive partitioning analyses, RA disease factors predicted work disability among older subjects, and functional limitation was the fourth most important factor. Job physical demand was not a significant or important factor. CONCLUSION: In this contemporary data from a large RA cohort, older age, lower income, fewer working hours, and preference not to work were the risk factors for work disability. The impact of disease factors was limited to subjects ages >or=56 years. Job physical demand level had little impact.

A method for imputing the impact of health problems on at-work performance and productivity from available health data.

OBJECTIVE: To develop a method for imputing the work performance and productivity impact of illness and treatment from available data. METHODS: Using data from four studies of musculoskeletal disorders (eg, osteoarthritis) and pain, we modeled the relationships between scores from the Work Limitations Questionnaire (WLQ), a validated measure of health-related limitations in work performance and productivity, and a series of validated health measures (eg, a pain scale). RESULTS: The 15 health and 5 WLQ variables were significantly associated in 115 of 116 study-specific models (P < 0.05). CONCLUSION: Fifteen commonly collected health variables may be used to predict WLQ impact (increase or decrease) for samples with musculoskeletal pain and physical impairments to help fill information gaps.

Problems experienced by people with arthritis when using a computer.

OBJECTIVE: To describe the prevalence of computer use problems experienced by a sample of people with arthritis, and to determine differences in the magnitude of these problems among people with rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia (FM). METHODS: Subjects were recruited from the Arthritis Network Disease Registry and asked to complete a survey, the Computer Problems Survey, which was developed for this study. Descriptive statistics were calculated for the total sample and the 3 diagnostic subgroups. Ordinal regressions were used to determine differences between the diagnostic subgroups with respect to each equipment item while controlling for confounding demographic variables. RESULTS: A total of 359 respondents completed a survey. Of the 315 respondents who reported using a computer, 84% reported a problem with computer use attributed to their underlying disorder, and approximately 77% reported some discomfort related to computer use. Equipment items most likely to account for problems and discomfort were the chair, keyboard, mouse, and monitor. Of the 3 subgroups, significantly more respondents with FM reported more severe discomfort, more problems, and greater limitations related to computer use than those with RA or OA for all 4 equipment items. CONCLUSION: Computer use is significantly affected by arthritis. This could limit the ability of a person with arthritis to participate in work and home activities. Further study is warranted to delineate disease-related limitations and develop interventions to reduce them.

Contemporary prevalence and incidence of work disability associated with rheumatoid arthritis in the US.

OBJECTIVE: To provide a contemporary estimate of the prevalence and incidence of rheumatoid arthritis (RA) work disability and examine its permanence over time. METHODS: Data were collected semiannually from 5,384 subjects with rheumatologist-diagnosed RA. We examined prevalence in subgroups formed by approximately 5-year disease duration intervals using data from subjects age < or =64 years who were employed at disease onset. Annual incidence was examined longitudinally among subjects who supplied data in 2003, 2004, or 2005, were employed at disease onset and in a year's first survey, and were age < or =63 years. For work disability permanence we used longitudinal data from all subjects who became work disabled and observed whether they later returned to work. RESULTS: Mean age of subjects was 52 years, 82% were female, 63% had more than a high school education, mean disease duration was 14 years, and mean Health Assessment Questionnaire score was 1.0. The prevalence of any premature work cessation was 23% in subjects with 1-3 years duration, 35% in those with 10 years, and 51% in those with > or =25 years RA duration. Arthritis-attributed work cessation was 14%, 29%, and 42%, respectively. Annual incidence of any premature work cessation was approximately 10% and arthritis-attributed work cessation incidence was approximately 6%. Thirty-nine percent of subjects who stopped working later returned to work. CONCLUSION: Work disability prevalence in this sample was high (35% within 10 years disease duration), but may represent a decline from the 50% prevalence reported in 1987. Annual incidence of work disability was higher than prior studies, but the return to work rate was also higher.

Evaluation of the effect of anti-tumor necrosis factor agent use on rheumatoid arthritis work disability: the jury is still out.

OBJECTIVE: To examine the role of anti-tumor necrosis factor (anti-TNF) agents in predicting work disability in subjects with rheumatoid arthritis (RA). METHODS: We studied 953 subjects with rheumatologist-diagnosed RA from a US cohort using a nested, matched, case-control approach. Subjects provided data on medication usage and employment every 6 months for 18 months, were employed at baseline, and were age <65 years at last followup. Cases were subjects who were not employed at followup (n = 231) and were matched approximately 3:1 by time of entry into the cohort to 722 controls who were employed at followup. Risk of any employment loss, or loss attributed to RA, at followup as predicted by use of an anti-TNF agent at baseline was computed using conditional logistic regression. Stratification on possible confounding factors and recursive partitioning analyses were also conducted. RESULTS: Subjects' mean age was 51 years, 82% were female, 92% were white, and 72% had more than a high school education. Nearly half (48%) used an anti-TNF agent at baseline; characteristics of anti-TNF agent users were similar to nonusers. In the main analyses, anti-TNF use did not protect against any or RA-attributed employment loss (odds ratio [95% confidence interval] 1.1 [0.7-1.6] versus 0.9 [0.5-1.5]). However, a protective effect was found for users with disease duration <11 years (odds ratio [95% confidence interval] 0.5 [0.2-0.9]). In recursive partitioning analyses, age, RA global severity, and functional limitation played a much greater role in determining employment loss than anti-TNF agent use. CONCLUSION: Anti-TNF agent use did not protect against work disability in the main analyses. In stratified analyses, their use was protective among subjects with shorter RA duration, whereas in nonparametric analyses, age and disease factors were the prominent predictors of work disability.

The prevalence and incidence of work disability in rheumatoid arthritis, and the effect of anti-tumor necrosis factor on work disability.

OBJECTIVE: To determine the prevalence and incidence rates of work disability in rheumatoid arthritis (RA), and to determine the effect of anti-tumor necrosis factor (TNF) therapy on work disability. METHODS: Participants with RA who were employed when RA was diagnosed (N = 8082) were evaluated for up to 5.5 years. Work disability incidence rates were determined in a subset (N = 4155) of those who stated they were currently employed, and the effect of anti-TNF therapy was determined by conditional logistic regression, after adjustment for covariates. RESULTS: At a median of 12.8 years after RA onset, 56.2% were still employed and 43.8% were not working. Of those not working, 22.7% considered themselves disabled. In addition, 30.5% had stopped work over their lifetimes for health reasons and 20.6% were currently receiving Social Security disability benefits. The annualized incidence rate for self-reported disability was 2.5% and for Social Security disability 1.9%. The incidence rate for persons who stopped working and did not resume employment was 4.0%. Anti-TNF therapy was not associated with Social Security disability, but was associated with an increased risk of self-reported disability (odds ratio 1.6) after adjustment for covariates. CONCLUSION: Rates of self-reported disability were lower than noted in previous studies, perhaps reflecting overall improvement in RA therapy. We could not discern a positive effect of anti-TNF therapy on the risk of work disability.

Extent of occupational hand use among persons with rheumatoid arthritis.

OBJECTIVE: Occupational hand use is increasing due to increased computer use and could place persons with rheumatoid arthritis (RA) at risk for work disability. Although hand involvement in RA is typical, there is little information about occupational hand use in relation to RA. Study objectives were to describe the extent of occupational hand use by persons with RA; the types of jobs that require extensive hand use; the relationship between occupational hand use and joint pain; and the extent of occupational hand use among persons with shorter versus longer disease duration. METHODS: Cross-sectional survey data from 2,761 employed participants with RA from a US national cohort were used. Extent of occupational hand use was measured by the hand-use item from a job physical demand scale used in prior RA studies. Analyses included descriptive statistics and chi-square tests. RESULTS: The mean age was 50.6 years, 78.5% were women, 91.8% were white, and 68.8% had more than a high school education. Eighty-three percent of participants reported extensive occupational hand use. Large portions of participants in all types of jobs reported extensive hand use, 92% with administrative support jobs and 69% with operator/laborer jobs. Participants with extensive occupational hand use were more likely to have hand joint pain than those with moderate hand use (66% versus 58%; P = 0.004). Extensive hand use did not vary by disease duration (83% and 84% in participants with < or =15 and >15 years' duration, respectively). CONCLUSION: Extensive occupational hand use was ubiquitous among employed persons with RA and was associated with greater hand pain.

Work disability and its economic effect on 55-64-year-old adults with rheumatoid arthritis.

OBJECTIVE: To examine the extent and financial impact of work disability among older workers with rheumatoid arthritis (RA). METHODS: Year 2002 data from 5,419 subjects with RA < 65 years of age in the National Data Bank for Rheumatic Diseases were used, along with US population data. Measures of work disability were employment status, part-time work, sick day use, and limitation in work demands; the latter was assessed by the Work Limitations Questionnaire (WLQ). Measures of financial status were median household income and poverty level income. Statistical procedures included logistic and linear regression, Wilcoxon's rank sum test, and chi-square test. RESULTS: Despite being better educated, subjects with RA ages 55-64 years had lower employment rates than individuals of the same age in the US (women 40% versus 53% and men 54% versus 66%). These older subjects with RA had stopped working more often than younger subjects with RA, and more worked part time (40% versus 34%; P < 0.01). However, the older subjects used sick time less often than younger subjects (35% versus 41%; P < 0.01) and were similarly limited in job demands, e.g., physical demands (mean WLQ subscale score 27.0 versus 26.6; P = 0.65). Median household income of older employed subjects was 20,000 dollars greater than that of retired subjects; 56% of retired subjects had incomes lower than US median income versus 32% of employed subjects, and 11% had income below the poverty level. CONCLUSION: Premature work cessation in persons with RA ages 55-64 years is a serious problem that needs to be addressed.

Reduction of job loss in persons with rheumatic diseases receiving vocational rehabilitation: a randomized controlled trial.

OBJECTIVE: Job loss is a major consequence of rheumatic diseases, and clinicians may refer patients to vocational rehabilitation for help. When provided after job loss, the impact of vocational rehabilitation is short term. This randomized controlled trial with 48 months of followup was undertaken to determine the efficacy of vocational rehabilitation provided to persons with rheumatic diseases while they are still employed, but at risk for job loss. METHODS: A total of 242 patients with rheumatic diseases residing in Massachusetts were recruited through their rheumatologists for study. Participants were randomly assigned to the experimental group (n = 122) or the control group (n = 120). Subjects in the experimental group received two 1.5-hour sessions of vocational rehabilitation; those in the control group received print materials about disability employment issues and resources by mail. The main outcome assessed was the time to first job loss. Job losses were defined as permanent disability, premature retirement, or a period of unemployment. All analyses were conducted on an intent-to-treat basis. RESULTS: Job loss was delayed in the experimental group compared with the control group (P = 0.03 by log rank test). After adjustment for confounders, participation in the experimental group was found to be protective against job loss (odds ratio 0.58 [95% confidence interval 0.34-0.99], P = 0.05 by pooled logistic regression). CONCLUSION: Vocational rehabilitation delivered to patients at risk for job loss, but while they were still employed, delayed job loss. Such an intervention has the potential to reduce the high indirect costs, as well as the personal impact, of rheumatic diseases.