Rheumatoid Arthritis Work Limitation Factors
Rheumatic and musculoskeletal diseases (RMD) introduce pain and functional limitations into the workplace, affecting individuals with rheumatoid arthritis and osteoarthritis. This study delves into the multifaceted factors that shape the work challenges arising from RMD, acknowledging the broader societal costs involved. By shedding light on these complexities, the research seeks to empower individuals grappling with RMD, offering valuable insights for health professionals and fostering a more supportive work environment.
THE BACKGROUND OF THE STUDY
Rheumatic and musculoskeletal diseases (RMD) present a multifaceted challenge, causing pain, fatigue, and functional limitations with implications for work participation [1]. Conditions like rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), osteoarthritis (OA), and fibromyalgia (FM) contribute to the global burden of work disability, posing financial costs at societal, organizational, and individual levels [1][2]. Global estimates of RMD prevalence underscore their significance, ranging from 0.46% in RA to 6.6% in FM [3][4][5][6].
Onset during working age emphasizes the potential for extended work with these conditions [1]. Understanding and managing RMD-related difficulties in the workforce is crucial due to its repercussions on the economy, especially in the United Kingdom, where expenses for osteoarthritis and rheumatoid arthritis alone are projected to reach £3.43 billion by 2030 [1][2]. Furthermore, this study is pertinent as countries raise pension ages, given that a third of UK workers are over 50, and individuals with RMD face increased risks of presenteeism, absenteeism, and work disability [1].
The UK Government’s ‘Improving Lives’ strategy aims to facilitate the inclusion of disabled individuals in the workforce, aligning with the imperative to enable people with disabilities or ill-health to remain employed [1][7]. Factors influencing presenteeism, absenteeism, and work disability in RMD encompass symptoms, functional limitations, psychological aspects, workplace conditions, and societal factors [8]. This study explores work limitations experienced by individuals with rheumatoid arthritis, axial spondyloarthritis, osteoarthritis, or fibromyalgia and explores associated factors aiding health and occupational professionals in crafting effective interventions [1].
THE STUDY METHOD
The study adopted a cross-sectional design, conducting a secondary analysis of a survey evaluating the psychometric properties of work patient-reported outcome measures in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), osteoarthritis (OA), and fibromyalgia (FM). Participants were recruited from diverse healthcare settings in the UK, including secondary care and community National Health Service (NHS) Trusts, along with a University Arthritis Volunteer Register.
Eligible participants, aged at least 18, engaged in paid work for at least one (1) day a week (including self-employed), currently at work, and diagnosed with RA, axSpA, knee and hip OA, or FM, formed the study cohort. Exclusion criteria encompassed long-term sick leave and language limitations, with provision for those on short-term ill leave to participate upon return to work.
A comprehensive literature search and overview review were conducted to identify factors associated with presenteeism, absenteeism, and work participation in the four rheumatic and musculoskeletal diseases. A total of 78 factors were identified, with 33 linked to variables available in the dataset.
Data collection spanned from March 2018 to March 2020. The Workplace Activity Limitations Scale (WALS) gauged work limitations, encompassing personal, health, and work characteristics. Condition-specific measures were included for RA, axSpA, OA, and FM. Additionally, assessments covered individual contextual factors, work-related environmental contextual factors, and the need for work adjustments and policies.
Responses within the dataset determined the sample size.
ANALYSIS
The study’s variables were summarized using descriptive statistics such as mean (standard deviation), median (interquartile range), and number (percentage). The one-way ANOVA, Kruskal-Wallis, and Chi-square tests were used to compare conditions. Statistical significance was set at p ≤ 0.05.
Multivariable regression, controlling for age and sex if relevant, examined independent variables associated with the Workplace Activity Limitations Scale (WALS) for each condition separately. Bivariate regression analyses identified variables for inclusion based on significance (p ≤ 0.05) and correlation (r ≥ 0.3). Pearson’s correlations assessed multicollinearity, and items were omitted if correlations were ≥0.8. Collinearity diagnostic tests were examined, and variables not meeting requirements were omitted.
Two multivariable regression analyses were conducted for each condition. Variables entered met selection criteria based on condition-specific literature and a cross-condition literature review. The forced entry method was used, sequentially dropping variables based on descending p values. Retained variables had a p-value ≤0.05. Analysis used SPSS v26 (IBM, 201).
RESULTS
The study provides an overview of key findings in the results section, highlighting differences and associations among participants with different rheumatic conditions.
Study Participants:
– 879 out of 1359 patients (64.7%) returned the study questionnaire.
– 822 participants (60.5% overall) were included, with 4.2% ineligible.
Personal Factors, Health, and Job Characteristics:
– Varied demographic characteristics among different rheumatic conditions.
– Participants with OA or RA were significantly older than those with axSpA or FM.
– Significant differences in living arrangements and children at home.
– Educational levels were similar across groups.
– AxSpA participants had longer diagnosis duration and more full-time employment.
Work Limitations:
– Participants with FM had higher Work Activity Limitation Scores (WALS) and more difficulties than RA, OA, and axSpA.
– High WALS scores indicated moderate to high work instability.
– Specific work limitations varied among conditions, e.g., concentration in FM hand-related issues in RA.
– FM participants received more help and adaptations.
Functioning and Disability Factors:
– FM participants are generally worse on generic measures; axSpA is often better than RA and OA.
– Differences in body parts affected; FM and OA reported more severe difficulties.
– AxSpA had higher work self-efficacy, work-health-personal life balance, and motivation to continue working.
Work-Related Contextual Factors:
– AxSpA participants worked longer hours, more often in small enterprises, and had greater work self-efficacy.
– Varied levels of job control, with FM reporting less managerial and organizational support.
– FM required more work accommodations than other conditions.
Factors Associated with Work Limitations:
– Various factors associated with work limitations, including personal, functioning, work-related personal, and environmental factors.
– Multivariable regression analyses showed different factors across conditions.
– Across conditions, functional limitations, job strain, pain, and work-life balance were associated with work limitations.
DISCUSSION
This study explored workplace activity limitations among individuals with rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), osteoarthritis (OA), and fibromyalgia (FM) using the Workplace Activity Limitations Scale (WALS), recognized as one of the optimal presenteeism measures for Rheumatic Musculoskeletal Diseases (RMD) by the Outcome Measures in Rheumatology Worker Productivity Group [9]. Work limitations were compared across conditions, revealing that FM participants experienced the highest limits. Unlike previous studies comparing RA and OA or RA and axSpA, this study encompassed all three illnesses. It also included FM, identifying gaps in knowledge about presenteeism and contextual factors in FM [9].
Notably, participants with FM reported worse function, pain, fatigue, job strain, work self‐efficacy, and work‐life balance than those with rheumatoid arthritis and OA, whereas RA exhibited better function scores. FM participants perceived less control over work, lower support, and required more accommodations. Fibromyalgia diagnosis delays may contribute to difficulties explaining work issues to employers, potentially resulting in more significant work challenges [9].
Workplace Activity Limitations Scale scores indicated moderate to high work instability for two-thirds or more of participants with OA, FM, and RA and just under half of those with axSpA. It suggested better disease control in axSpA, possibly associated with biologics use. However, in RA, participants exhibited moderate to high work instability scores alongside relatively low Health Assessment Questionnaire (HAQ) function scores [9].
Participants reported difficulties with a substantial portion of work activities yet only received help or adaptations for a quarter or less, highlighting the need for workplace adaptations, especially for those with moderate and high work instability [9]. Factors associated with greater presenteeism were identified across conditions, with a functional decline seen in all the illnesses. Other condition-specific factors included tremendous job strain, the need for work accommodations, poorer work-life balance, more significant pain, greater mental–interpersonal job demands, lower perceived work support, worse perceived health, and poorer work self‐efficacy [9].
Disclosing the condition to employers did not eliminate the need for work accommodations, and participants reported challenges, including a need for more understanding and support from employers [9]. Overlapping factors associated with greater presenteeism highlighted the importance of considering modifiable factors in non-pharmacological interventions, emphasizing the need for active employer engagement [9].
This study’s findings align with research in general working populations, emphasizing the similarity of factors affecting presenteeism in RMDs to those influencing the general working population. The study advocates for condition-specific vocational rehabilitation alongside broader workplace practices, such as flexible working arrangements, home or hybrid working, and effective line management practices to mitigate presenteeism [9].
LIMITATIONS OF THE STUDY
- Cross-Sectional Design: The study’s cross‐sectional nature limits establishing causality, as it does not allow for examining causal relationships. Longitudinal studies would be necessary to explore causation over time.
- Sampling Bias: Participants were recruited from community and hospital outpatient clinics, introducing a potential selection bias. This sample may not fully represent the entire population with these conditions. The absence of consecutive sampling further limits the generalizability of findings, as recruitment depends on the availability of research nurses/facilitators and therapy staff.
- Self-Selection Bias: While the study emphasized eligibility for those with no or few work problems, the voluntary nature of participation raises the possibility of self-selection bias. Individuals experiencing minimal work problems may have been more inclined to participate, potentially skewing the study’s perspective.
- Gender Disparity in FM Participants: The study faced challenges in recruiting a sufficient number of men with Fibromyalgia (FM), leading to underrepresentation. This gender disparity might limit the generalizability of findings, particularly for male individuals with FM.
- Study Focus and Design: The WORK‐PROM study primarily aimed to evaluate the psychometrics of measures rather than comprehensively evaluating factors influencing presenteeism. This limited scope may have overlooked various important variables influencing work-related outcomes.
- Literature Review Gaps: The literature review acknowledged that several potentially significant variables were not included in the study. The omission of factors such as compensation for absence, income needs, and family support, identified by the Outcome Measures in Rheumatology Worker Productivity Group (Boonen et al., 2021), indicates a gap that may affect the completeness of the study’s findings.
In summary, while the study provides valuable insights, its cross‐sectional design, sampling approach, potential self-selection bias, gender disparity in FM participants, study focus, and literature review gaps introduce limitations that should be considered when interpreting the results. Future research with a more diverse and representative sample, longitudinal design, and comprehensive consideration of relevant variables could address some limitations.
CONCLUSION
In conclusion, this study enhances understanding of work limitations in individuals with rheumatoid arthritis, axSpA, OA, and FM, revealing significant work instability and a need for increased accommodation support. While the findings may be more applicable to those treated in therapy and outpatient clinics, the high prevalence of work limitations in FM suggests a broader need for work support. The study identifies personal and contextual factors associated with presenteeism, emphasizing the importance of early identification and tailored work interventions to prevent future disability. Health professionals play a crucial role in initiating such support, contributing to the overall goal of maintaining individuals with rheumatic and musculoskeletal diseases in the workforce.
REFERENCES
- Gignac, M. A. M., Cao, X., & Tang, K. (2011). Psychosocial work factors and processes influencing older workers’ health: A 3-year longitudinal analysis. Journal of Aging and Health, 23(3), 547-578. https://acrjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/acr.20456
- Bevan, S., Quadrello, T., McGee, R., Mahdon, M., Vavrovsky, A., & Barham, L. (2013). Fit for work? Musculoskeletal disorders in the European workforce. The Work Foundation. https://www.bl.uk/collection-items/reducing-temporary-work-absence-through-early-intervention-the-case-of-msds-in-the-eu
- Almutairi, K., Nossent, J., & Preen, D. (2021). The worldwide prevalence of rheumatoid arthritis: A systematic review and meta-analysis. Clinical Rheumatology, 40(2), 271-281. https://pubmed.ncbi.nlm.nih.gov/33175207/
- Stolwijk, C., van Onna, M., Boonen, A., van Tubergen, A., & Global SpA Research Alliance (2016). Global prevalence of spondyloarthritis: A systematic review and meta-regression analysis. Arthritis Care & Research, 68(9), 1320-1331. https://pubmed.ncbi.nlm.nih.gov/26713432/
- Cui, A., Li, H., Wang, D., Zhong, J., Chen, Y., & Lu, H. (2020). Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine, 29-30, 100587. https://doi.org/10.1016/j.eclinm.2020.100587
- Heidari, B., Hajian-Tilaki, K., & Heidari, P. (2017). Musculoskeletal pain and its associated factors in Iranian population: A nationwide multicenter study. Clinical Rheumatology, 36(11), 2577-2589. https://pubmed.ncbi.nlm.nih.gov/21199469/
- Department of Work and Pensions (DWP) & Department of Health (DH). (2017). Improving Lives: The Future of Work, Health and Disability. UK Government.https://www.gov.uk/government/publications/improving-lives-the-future-of-work-health-and-disability
- Gilworth, G., et al. (2003). Rheumatic and musculoskeletal diseases in the workforce: A review of literature and identification of knowledge gaps. Arthritis Care & Research, 49(5), 625-631. https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.1111
- Brown ET, et al. (2023). Workplace activity limitations in rheumatic and musculoskeletal diseases: A multicenter cross-sectional study. *Musculoskeletal Care,* 21(3), 828-841. https://doi.org/10.1002/msc.1760
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