Effect of arthritis and other rheumatic conditions on employment

Transcription

1 Work 45 (2013) DOI /WOR IOS Press Working with Arthritis Effect of arthritis and other rheumatic conditions on employment Saralynn J. Allaire, Rawan AlHeresh and Julie J. Keysor Boston University, College of Rehabilitation and Health Sciences, Boston, MA, USA Keywords: Arthritis, prevalence, employment, work disabiliy 1. Introduction Because arthritis is often thought of as mild joint pain in the elderly, it may be surprising to learn it is a major cause of work disability. Over 5% of all employmentaged adults (18 64 years), which is close to 6.9 million people, have some limitation in ability to work due to arthritis [22]. The term arthritis encompasses a large number of conditions which have joint inflammation as a component. Arthritis conditions (major types plus fibromyalgia) are common, even among persons under age 65 years, i.e., 30% of Americans aged and 7.6% of those aged years self-reported a physician diagnosed arthritis condition in US population data [7]. In 2002 U.S. population data, about 30% of people with arthritis conditions reported being unable to work or being limited in the type or amount of work they could do because of arthritis [22]. In this review, we describe the impact of several prominent arthritis conditions that can have a substantial impact on employment outcomes of individuals living with the condition: i) osteoarthritis, ii) inflammatory arthritis conditions (i.e., rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, iii) systemic lupus erythematosis, iv) systemic sclerosis (scle- Corresponding author: Saralynn J. Allaire, Assistant Director ENACT Grant, 635 Commonwealth Avenue, 6 th Floor, Boston, MA 02118, USA. Tel.: ; Fax: ; sallaire@bu.edu. roderma), and v) fibromyalgia. For each condition we briefly review disease pathophysiology, the major signs and symptoms of disease and how they impact employment, and disease prevalence and work disability epidemiology. 2. Osteoarthritis Osteoarthritis (OA) is the most prevalent type of arthritis; data corresponding to the 2005 US population indicated 27 million Americans had clinical OA (joint signs including pain) [16]. Given its high prevalence, OA is typically the condition most people think of as arthritis. The prevalence of OA is increasing due to the aging of the population and obesity and will continue to have a substantial impact on society well into the future [13]. OA is a non-systemic disease process with inflammation that affects a relatively limited number of joints, i.e., knees, hips, distal and proximal interphalangeal finger and carpometacarpal thumb joints, lower back and neck. The condition frequently results in chronic pain and stiffness in affected joints and limited range of motion. Walking, prolonged sitting and standing, opening jars and doors, and even writing can become painful and difficult, and these effects may limit many work-related activities. Studies show a supportive work environment facilitates job retention among persons with arthritis [15,23]. The effects of OA are somewhat /13/$ IOS Press and the authors. All rights reserved

2 418 S.J. Allaire et al. / Effect of arthritis and other rheumatic conditions on employment invisible to others, especially at an early disease stage, and this may reduce opportunity to obtain necessary support from others at work. However, due to the frequency of OA in older persons, OA symptoms may seem normal and accepted easily by others. Walking aids and splints increase visibility. OA obviously causes a great deal of work disability, as the 2002 U.S. population data on arthritis work disability cited previously [22], primarily reflect the effects of OA. The effect of OA on employment may be greater on productivity, i.e., limitation in the type and amount of work, than inability to work. Two studies of participants with clinically well defined knee OA found little premature work cessation [1,2]. However, the samples included relatively few participants with heavy manual jobs, and physical job activities are associated with high rates of OA in the joints used, e.g., workers with jobs requiring bending and lifting have more than double the rate of knee OA [9]. The physical demand of US jobs overall has declined though. Evidence of selective work cessation among progressively older workers with OA was found in one U.S. population based study of American workers [20]. Still employed workers in this study were much more likely to work part time than those without OA, and this and other studies have found evidence of productivity loss, especially among those with pain flares [10,17,20]. 3. Highly inflammatory forms of arthritis Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are referred to as inflammatory arthritis conditions. The prevalence of these diseases is much lower than that of OA: rheumatoid arthritis 1.3 million U.S. adults, and PsA, AS and other spondyloarthropathies together 0.6 to 2.4 million adults [11]. Due to the greater amount of inflammation, joint swelling is more extensive in these diseases, as is joint stiffness, especially after arising from rest. Pain is also of course a substantial problem. While these diseases primarily affect the joints, there are in addition body wide, i.e., systemic, effects including constitutional symptoms like fatigue, as well as organ effects. Muscles may also be involved which may substantially reduce strength. There is a pattern of disease flare (increased disease activity) and remission in these diseases, but many individuals have some level of continued disease activity, so remission is relative. Due to the systemic nature of these diseases, job activities requiring energy, stamina and endurance may be impaired in addition to those that are physically demanding. Repetitive activities are apt to increase joint inflammation. Disease effects are often invisible in the early stages, which can lead to disbelief and lack of support from co-workers and others. The flare and remission pattern of symptoms also can be difficult for others to understand. Visibility is increased if deformities occur, as do use of splints or other adaptive devices. The medical treatment of these conditions has improved dramatically in the past years through use of newer medications combined with biologic agents. The cost of biologic agents is high, e.g., $23,000 and more annually, which has significant financial and health insurance implications for individuals. The rates of premature work cessation associated with these diseases have been high, e.g., 50% at 10 years disease duration in RA [24]. However, the rate of work cessation in RA appears to have declined somewhat in recent years, e.g., 35% at 10 years disease duration [3]. This is probably due, at least in part, to reduction in disease activity from improved medical treatment. 4. Systemic lupus erythematosis (SLE) This highly inflammatory disease can affect any body system; skin, kidney, heart/lung, blood, central nervous (CN) and musculoskeletal systems are commonly affected. Not all systems are affected in any individual, but rather the configuration of systems affected varies per person. However, most individuals have some degree of arthritis. SLE is fairly unique among the rheumatic diseases in its possible effect on the CN system. Another unique feature is sensitivity to ultraviolet light, which can trigger a disease flare in some individuals. The prevalence of SLE in the U.S. is between 161,000 and 322,000 adults [11]. As with inflammatory arthritis, there is a pattern of disease flare (increase in disease activity) and remission in SLE, and many individuals have some level of continued disease activity in remission. Flares may affect organ function and sometimes require hospitalization. Advances in treatment have generally been organ specific, e.g., improved treatment of kidney disease. Advances in treatment of disease process have not been as substantial as with the inflammatory arthritis diseases; the one biologic agent developed thus far has limited application. Corticosteroids and immunosup-

3 S.J. Allaire et al. / Effect of arthritis and other rheumatic conditions on employment 419 pressive drugs are sometimes necessary to treat severe disease effects, but prolonged and high usage of corticosteroids in particular can result in additional health problems. The most recent U.S. study found that 40% of participants with SLE reported premature work cessation 10 years after disease onset [25]. However, another 40% of participants not working at study start became employed during the 2 3 year follow-up period; this is probably a reflection of the younger age of onset in this disease and changes in lupus treatment. Importantly, though, this work entry rate was lower than that of non-affected peers. Limitation in physical job activities is common in SLE due to arthritis and can be enhanced by the disease s effects on other organs. Some individuals have severe energy limitations making full-time work very challenging; attention to energy conservation for these individuals is critical to optimize employment outcomes. Memory, attention and higher executive function cognitive impairments, if moderate to severe, are especially likely to affect ability to work [4]. For persons who are sensitive to ultraviolet light, avoidance of fluorescent lighting and sunlight is necessary. Despite the significant impact SLE can have on body systems, the condition tends to be highly invisible. Some medications, particularly corticosteroids, can create a chubby flushed appearance, which is often interpreted as looking healthy. These factors, coupled with a lack of public awareness of the disease and its varied clinical presentation, can create disbelief and lack of support in others. However, many persons with SLE are hospitalized at some point and this may increase awareness of the seriousness of the condition. 5. Systemic sclerosis (Scleroderma) This uncommon disease (49,000 U.S. adults) [11] affects mainly the skin and internal organs, although like SLE, many persons have some degree of arthritis. The disease process causes fibrosis of the skin (skin hardening) and organs such as peripheral blood vessels, gastrointestinal system, kidney, heart and lungs. Most persons have Raynaud s phenomenon, i.e., vasospasm of peripheral blood vessels to cold and stress causing, in persons with scleroderma, severe restriction of blood flow. There are two basic subtypes of the disease; in one subtype severe disease effects tend to occur early after onset and subside somewhat with time while in the other subtype disease effects accumulate slowly over time. Treatment is generally organ specific. Control of blood vessel vasospasm via medications and body warmth maintenance is especially important. There is no specific treatment for the disease. One recent US study suggested the work disability rate is 40% in persons with early moderate to severe scleroderma; lung disease and fatigue were substantial work disability predictors [21]. Because of blood vessel vasospasm, exposure to cold and drafts needs to be avoided. Effects of scleroderma on hand activities tend to be substantial [5,6]. Finger and wrist range of motion may be limited due to tightness of the hardened skin. Finger tip ulcers are common due effects of Raynaud s phenomenon. Endurance may be limited by lung or heart effects. This disease is also fairly invisible, especially during early years. 6. Fibromyalgia Fibromyalgia is a condition that causes diffuse musculoskeletal pain and tenderness. As it does not affect joints, fibromyalgia is not a form of arthritis. Rather, it may be a sensory processing disorder that causes pain and unpleasantness to low thresholds of stimuli, or it may involve neurochemical abnormalities [8]. The condition is often accompanied by fatigue, memory difficulties, sleep disturbance, irritable bowel symptoms and depression. Fibromyalgia is common, affecting 5 million U.S. Adults [16]. Rates of work disability associated with fibromyalgia range from 25 to 33% [12,14]. Women with fibromyalgia report limited energy and endurance in physical activities; many work part time [18,19]. Jobs with high psychosocial demand, frequent changes, or limited control over activities and work hours can be difficult. Many persons with fibromyalgia also report having cognitive difficulties, such as poor memory. Lack of support from co-workers and supervisors is common, as the illness is invisible. Flextime schedules and ability to control and change work activities can be helpful. Acknowledgements The authors work is supported by NIDRR center grant no. H133B100003, Enhancing Activity and Participation among Persons with Arthritis (ENACT).

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