Work disability among women with rheumatoid arthritis. The relative importance of disease, social, work, and family factors

Factors Associated With Household Work Limitations in Mexican Patients With Rheumatoid Arthritis: The Impact of the Disease on Women's Life

BACKGROUND

Little attention has been given to the impact of rheumatoid arthritis (RA) on domestic work, which remains the domain of women, particularly in the Latin American region. The study identified factors associated with RA-related household work limitations (HOWL) in Mexican for women with long-standing disease.

METHODS

This cross-sectional study was performed between September 2020 and April 2022, in patients from the recent-onset RA cohort (initiated in 2004). At study entry, patients had standard rheumatic assessments and were administered the HOWL questionnaire, a survey to assess family responsibilities, household work characteristics, and the patient's economic dependency, and the family APGAR index to assess family function. Multiple logistic regression analysis identified variables associated with RA-related HOWL.

RESULTS

Data from 114 female RA patients were analyzed. Overall, at cohort entry, patients were middle-aged (median, 37.5 years), with 12 years of education, and the minority (n = 42 [39.3%]) were married or living together. Patients were representative of typical patients with recent-onset disease and had significant disease activity. At study entry, the patients had 12 (7-16) years of disease duration, and their disease was under control. The median (interquartile range) HOLW-Q score was 0.67 (0-3.33), and 33 patients (28.9%) had RA-related HOWL. Receiving financial support for family living expenses, requiring assistance for activities of daily living, and DAS28 (Disease Activity Score, 28 joints evaluated) were associated with RA-related HOWL; meanwhile, a better Short-Form 36 score at disease onset was protective.

CONCLUSIONS

Domestic work in Mexican RA women might be impacted by social determinants, health-related quality of life at disease onset, and current disease activity status.

Defining independence: A scoping review by the OMERACT patient perspective of remission in rheumatoid arthritis group

AIMS

The Outcome Measures in Rheumatology Trials (OMERACT) Remission in Rheumatoid Arthritis (RA) patient perspective working group has previously found that patients prioritised independence, pain, and fatigue as key domains of remission in RA. However, there is currently no clear definition of independence. Consequently, this scoping review aimed to explore how independence is represented in the RA literature.

METHODS

A comprehensive search of the EMBASE, Medline, and PsycInfo databases was performed for publications that used independence or autonomy as a disease activity measure, description of disease in remission or treatment outcome. Papers were included if they involved adult participants and were written in English, with no restrictions on study design or publication year. Two reviewers (TK and AC, AT or BJ) independently screened the abstracts. A thematic approach was applied to derive common definitions and descriptions of independence.

RESULTS

660 articles were identified, of which 58 (25 qualitative, 28 quantitative, one mixed, and four reviews) met the inclusion criteria. 86% of total participants were female. Ten publications referenced remission. Independence took many forms; in addition to physical and functional capability, it was described in relation to work, social activities, autonomy in healthcare, and household activities. Four common themes describing independence were identified: 1. A return to a state before arthritis. 2. Being physically and functionally able. 3. A sense of freedom without needing to rely on others. 4. Having control over the organisation of one's life.

CONCLUSION

Although independence is frequently mentioned in the RA literature, it has various meanings, lacks a consistent definition, and is a concept rarely applied to remission. It is multi-factorial, exceeding functional ability alone, and contextualised within sociodemographic and disease factors. This scoping review provides common descriptions of independence to inform future qualitative work towards the development of an outcome measure of independence for the assessment of RA in remission.

Relationship between polymorphisms in -572G/C interleukin 6 promoter gene polymorphisms (rs1800796) and risk of rheumatoid arthritis: A meta-analysis

AIMS

This meta-analysis was aimed to investigate the association between -572G/C interleukin (IL)-6 gene polymorphism and occurrence risk of rheumatoid arthritis (RA).

METHODS

Literature search was conducted in PubMed, Embase, Springer and Google Scholar up to November 2018. The pooled odds ratios (ORs) and 95% confidence interval (CI) were calculated by Revman 5.3.

RESULTS

A total of six case-control studies were included in this meta-analysis. In the allele model (G vs C), homozygous gene model (GG vs CC), recessive gene model (GG vs GC + CC), and dominant gene model (GG + GC vs CC), the pooled estimate indicated there was significant association between -572G/C IL-6 gene polymorphism and risk of RA. However, no significant statistical results were found in meta-analyses of heterozygote gene models.

CONCLUSIONS

The -572G/C IL-6 gene polymorphism is associated with the risk of RA. The GG genotype may be the main contributor in increasing susceptibility to RA.

Trends in Joint Replacement Surgery in Patients with Rheumatoid Arthritis

Objective.

This study analyzed trends in large total joint arthroplasties (TJA) and in the proportion of these procedures performed on patients with rheumatoid arthritis (RA).

Methods.

The US Nationwide Inpatient Sample (2002–2012) was used to identify the incidences of total shoulder (TSA), elbow (TEA), knee (TKA), hip (THA), and ankle (TAA) arthroplasty and the proportion of these performed with coexisting RA.

Results.

The prevalence of RA among patients with TJA increased 3.0%. The prevalence of RA among cases of TEA and TSA decreased by 50% (p < 0.0001) and 18% (p = 0.0016), respectively; a 38.0% decrease occurred in the prevalence of RA among TAA (p = 0.06); and nonsignificant increases were seen among THA and TKA. The average age difference between RA and non-RA patients undergoing TJA narrowed by 2 years (p < 0.0001). There was a greater reduction in the proportion of TSA, TEA, and TAA groups among women with RA than men with RA. In the TSA and TEA groups, there was a reduction in the proportion of whites with RA, but not blacks. The proportion of privately insured TSA and TAA patients with RA decreased, while patients with RA undergoing TSA, TEA, or TAA who were receiving Medicaid (government medical insurance) remained relatively stable over time.

Conclusion.

The prevalence of RA has decreased among TSA and TEA patients. A nonsignificant decline occurred among TAA patients. The average age of TJA patients with RA is beginning to mirror those without RA. Sex ratios for TSA, TEA, and TAA patients are following a similar pattern. These results may be evidence of the success of modern RA treatment strategies.

The contribution from psychological, social, and organizational work factors to risk of disability retirement: a systematic review with meta-analyses

BACKGROUND

Previous studies indicate that psychological, social, and organizational factors at work contribute to health, motivation, absence from work, and functional ability. The objective of the study was to assess the current state of knowledge of the contribution of psychological, social, and organizational factors to disability retirement by a systematic review and meta-analyses.

METHODS

Data sources: A systematic literature search for studies of retirement due to disability in Medline, Embase, and PsychINFO was performed. Reference lists of relevant articles were hand-searched for additional studies.

DATA EXTRACTION

Internal validity was assessed independently by two referees with a detailed checklist for sources of bias. Conclusions were drawn based on studies with acceptable quality.

DATA SYNTHESIS

We calculated combined effect estimates by means of averaged associations (Risk ratios) across samples, weighting observed associations by the study's sample size. Thirty-nine studies of accepted quality were found, 37 of which from the Nordic countries.

RESULTS

There was moderate evidence for the role of low control (supported by weighted average RR = 1.40; 95% CI = 1.21-1.61) and moderate evidence for the combination of high demands and low control (although weighted average was RR = 1.45; 95% CI = 0.96-2.19) as predictors of disability retirement. There were no major systematic differences in findings between the highest rated and the lowest rated studies that passed the criterion for adequate quality. There was limited evidence for downsizing, organizational change, lack of employee development and supplementary training, repetitive work tasks, effort-reward imbalance to increase risk of disability pension. Very limited evidence was found for job demands, evening or night work, and low social support from ones superior.

CONCLUSIONS

Psychological and organizational factors at work contribute to disability retirement with the most robust evidence for the role of work control. We recommend the measurement of specific exposure factors in future studies.

The Social Patterning of Work Disability Among Women in Canada

Although work disability is widespread among women with physical or mental impairment, little is known about its gendered nature. Drawing on the disablement and women's health literatures, it is argued that labor-market resources and participation in normatively structured social roles may be important in shaping women's work disability. Using data from a Canadian probability sample of community dwellers with disabilities, the paper examines the effects of functional limitation, labormarket resources, stage in the life course, and family roles on work disability. It also assesses the extent to which the relationship between social roles and disability depends on women's socioeconomic circumstances. Results indicate that younger individuals, married women, and those with high levels of homemaking responsibilities were less likely to report work disability than their counterparts without these social resources and roles. The impact of the parental role (children in the household) on work disability varied according to education.

Effects of Morphine and Time of Day on Pain and Beta-Endorphin

Clients report more pain at some times of day than at others due, in part, to the temporal variation of the body's inhibitory pain response. The analgesic effectiveness of morphine varies with the time of day, perhaps due to the inhibiting or enhancing effects of the drug on plasma beta-endorphin (BE). This experiment was designed to examine the timed effects of morphine on the pain-induced BE response. Six groups of treatment mice (injected with morphine sulfate) and 6 groups of control mice (injected with saline) were exposed to an acute pain stimulus at 4-h intervals, and blood was collected. Plasma BE was analyzed using radioimmunoassay. Control mice showed a robust cir-cadian BE-response rhythm with a peak at 0000 and a nadir at 1200, whereas the BE response of mice that received morphine was arrhythmic. Animals that received morphine tolerated the noxious stimulus longer, but the analgesia varied with time of day. These results indicate that morphine abolishes the rhythmic BE response to pain and does not inhibit pain equally at all times of day. Morphine doses should be titrated to maximize the endogenous pain control system while achieving analgesia with decreased dosages.

A survey of factors affecting the capacity to work in patients with rheumatoid arthritis in South Wales

A survey was undertaken during 1992-93 to identify factors associated with the severity of rheumatoid arthritis and its management which might be modified to improve the patient's ability to continue to work. Two hundred and twenty patients taking part in a trial of second-line therapy were sent a postal questionnaire. Seventy-four per cent returned valid forms and these patients were subsequently medically examined. The unemployment rate in males was 71 % and in females 69%, compared to the average for the whole of Wales of 27% and 42% respectively in the same age range for the year in question. The data obtained suggested that improvements could be made with respect to disease control, organization of medical care and better use of rehabilitation services to optimize ability to work.

Disability Transitions for Older Persons with Arthritis

This article reports changes over 2 years in physical, activities of daily living (ADL), and instrumental activities of daily living (IADL) disabilities for older U.S. adults with arthritis, compared to those without arthritis. The data source is the 1986 Longitudinal Study on Aging, a follow-up survey of community-dwelling persons ages 70 and over when first interviewed in 1984 (N = 4,717). Disability is defined as difficulty doing an activity on one's own and without special equipment. Transitions from tO status (1984: No Difficulty, Yes Difficulty) to ti status (1986: No Difficulty-Community Dwelling, Yes Difficulty-Community Dwelling, Institutional Residence, Dead) are studied. (a) Among nondisabled persons at to, people with arthritis are more likely to incur all types of disability over a 2-year period. (b) Among disabled persons at tO, those with arthritis regain ADL, IADL, and walking abilities more readily than do their nonarthritis peers, but they are less likely to regain physical functions requiring endurance, strength, and dexterity. (c) Regardless of initial disability status, nonarthritis people are more likely to be institutionalized or die in 2 years than are arthritis persons. (These results are clear but vary in statistical strength: Most comparisons for [a] are significant at p ≤ .01; one third are significant at p≤ .05 for [b]; most comparisons for institutional outcome are nonsignificant due to small cell sizes; one third for dead outcome are significant at p ≤ .01.) The results reflect the medical nature of arthritis (musculoskeletal locale, moderate impact, nonfatal) and also people's successful accommodations to it. In sum, disability is an especially dynamic experience for persons with arthritis. Clinical and public health efforts to prevent disability onset and to aid restoration of function for this common disease can have high payoff, benefiting many persons for relatively low cost.

Measuring the Impact of Arthritis on Worker Productivity: Perspectives, Methodologic Issues, and Contextual Factors

Leading up to the Outcome Measures in Rheumatology (OMERACT) 10 meeting, the goal of the Worker Productivity Special Interest Group (WP-SIG) was to make progress on 3 key issues that relate to the application and interpretation of worker productivity outcomes in arthritis: (1) to review existing conceptual frameworks to help consolidate our intended target and scope of measurement; (2) to examine the methodologic issues associated with our goal of combining multiple indicators of worker productivity loss (e.g., absenteeism <—> presenteeism) into a single comprehensive outcome; and (3) to examine the relevant contextual factors of work and potential implications for the interpretation of scores derived from existing outcome measures. Progress was made on all 3 issues at OMERACT 10. We identified 3 theoretical frameworks that offered unique but converging perspectives on worker productivity loss and/or work disability to provide guidance with classification, selection, and future recommendation of outcomes. Several measurement and analytic approaches to combine absenteeism and presenteeism outcomes were proposed, and the need for further validation of such approaches was also recognized. Finally, participants at the WP-SIG were engaged to brainstorm and provide preliminary endorsements to support key contextual factors of worker productivity through an anonymous “dot voting” exercise. A total of 24 specific factors were identified, with 16 receiving ≥ 1 vote among members, reflecting highly diverse views on specific factors that were considered most important. Moving forward, further progress on these issues remains a priority to help inform the best application of worker productivity outcomes in arthritis research.

Work disability remains a major problem in rheumatoid arthritis in the 2000s: data from 32 countries in the QUEST-RA study

INTRODUCTION

Work disability is a major consequence of rheumatoid arthritis (RA), associated not only with traditional disease activity variables, but also more significantly with demographic, functional, occupational, and societal variables. Recent reports suggest that the use of biologic agents offers potential for reduced work disability rates, but the conclusions are based on surrogate disease activity measures derived from studies primarily from Western countries.

METHODS

The Quantitative Standard Monitoring of Patients with RA (QUEST-RA) multinational database of 8,039 patients in 86 sites in 32 countries, 16 with high gross domestic product (GDP) (>24K US dollars (USD) per capita) and 16 low-GDP countries (<11K USD), was analyzed for work and disability status at onset and over the course of RA and clinical status of patients who continued working or had stopped working in high-GDP versus low-GDP countries according to all RA Core Data Set measures. Associations of work disability status with RA Core Data Set variables and indices were analyzed using descriptive statistics and regression analyses.

RESULTS

At the time of first symptoms, 86% of men (range 57%-100% among countries) and 64% (19%-87%) of women <65 years were working. More than one third (37%) of these patients reported subsequent work disability because of RA. Among 1,756 patients whose symptoms had begun during the 2000s, the probabilities of continuing to work were 80% (95% confidence interval (CI) 78%-82%) at 2 years and 68% (95% CI 65%-71%) at 5 years, with similar patterns in high-GDP and low-GDP countries. Patients who continued working versus stopped working had significantly better clinical status for all clinical status measures and patient self-report scores, with similar patterns in high-GDP and low-GDP countries. However, patients who had stopped working in high-GDP countries had better clinical status than patients who continued working in low-GDP countries. The most significant identifier of work disability in all subgroups was Health Assessment Questionnaire (HAQ) functional disability score.

CONCLUSIONS

Work disability rates remain high among people with RA during this millennium. In low-GDP countries, people remain working with high levels of disability and disease activity. Cultural and economic differences between societies affect work disability as an outcome measure for RA.

A two‐year follow‐up of work capacity in early rheumatoid arthritis: a study of multidisciplinary team care with emphasis on vocational support

OBJECTIVE

To explore changes in sick leave patterns and work ability in patients with early rheumatoid arthritis (RA). The patients received active team support focusing on vocational rehabilitation, in addition to treatment with disease-modifying anti-rheumatic drugs (DMARDs).

METHODS

This is an observational study of 110 patients with early RA aged 18-60 years and not permanently disabled. All patients were monitored regularly during a 2-year period by a team comprising a nurse, an occupational therapist, a physiotherapist, a rheumatologist, and a social worker. Intervention included work-site visits and rehabilitation meetings with the employer and the official from the local social insurance office in addition to DMARD treatment and different individual treatments, and support from the team members.

RESULTS

The number of patients working full-time increased from 65 to 74 (14%), those with full-time work disability decreased from 37 to 13 (65%), and patients working part-time increased from 8 to 23 (65%). This change was already evident during the first year.

CONCLUSION

Active vocational support in addition to DMARD treatment may prevent or delay work disability in patients with early RA.

Work in inflammatory and degenerative joint diseases

This article focuses on work disability and sick leave and their cost; it also discusses the value of vocational rehabilitation programmes in rheumatic conditions such as rheumatoid arthritis, ankylosing spondylitis, hip and knee osteoarthritis. It acknowledges the importance of work not only for the worker who has one of these diseases but also for the public purse. Much can be done to improve the health of the persons and reduce their disability and its impact in the workplace which will have an important effect on their and their family's quality of life. It is important that neither rehabilitation nor vocational rehabilitation are regarded as bolt-on activities after drug treatment but are seen as an integral part of effective management. Publications dealing with return to work are relatively common in rheumatoid arthritis, less common in ankylosing spondylitis and relatively rare in osteoarthritis. Vocational rehabilitation programmes should aim to facilitate job retention or, failing that, to improve the ability to return to work. The process must be started with in the health arena and it has to be recognised that slow or poor practice in the health service can jeopardise the patient's work potential.

Work disability in scleroderma is greater than in rheumatoid arthritis and is predicted by high HAQ scores

Objectives

To estimate the frequency of work disability (WD) in a cohort of patients with Systemic Sclerosis (SSc) vs an internal control group of patients with rheumatoid arthritis (RA) with a known high frequency of WD; and to investigate the association between WD and other factors including Health Assessment Questionnaire Disability Index (HAQ-DI) scores, HAQ pain, age, sex, disease duration and education level.

Methods

Cross-sectional data on WD status were obtained from a questionnaire sent to all SSc (n = 35 limited [lcSSc], 26 diffuse [dcSSc]) and a subset of RA patients (n=104) from a rheumatology practice. WD data, HAQ-DI scores, and demographic/clinical features (age, sex, high school education, disease duration and SSc disease subtype [dcSSc vs lcSSc]) were recorded.

Results

The proportion with WD was 0.56 in SSc (95% CI: 0.43-0.68) vs 0.35 in RA (95% CI: 0.25-0.44), p= 0.009. HAQ-DI scores were significantly higher in work-disabled SSc and RA patients vs those who were employed (p=0.0001, and p <0.0001). Multivariate logistic regression analysis demonstrated that higher HAQ-DI scores (β=1.78, p <0.001), disease type (dcSSc, lcSSc, RA) (β=1.32 for dcSSc, p=0.032), and self-reported disease duration (β=0.04, p=0.042) were significantly associated with WD (R²=0.311). Adding a work-related factor (self-reported physically demanding work) improved the regression model (R²=0.346) and strengthened the HAQ-DI (β=1.86, p <0.001) and lcSSc (β=1.24, p=0.024) coefficients.

Conclusion

The frequency of WD in SSc was high and was greater than in RA. SSc (and dcSSc) had significantly more WD than RA. The HAQ-DI was strongly associated with WD in SSc

Towards a biopsychosocial framework of osteoarthritis of the knee

Research into the causes of osteoarthritis (OA) of the knee has traditionally followed a biomedical approach whereby the disease development and progression is regarded as an internal physiological process. As a result, treatment has focused on symptom reduction with limited modification of psychosocial variables. In fact, psychosocial factors such as environment and employment play a substantial role in the disease process and are important determinants of the overall level of disability of affected individuals. Thus, by placing greater importance on the biomedical aspects of knee OA, a complete representation of the health condition cannot be achieved thereby limiting treatment effectiveness. The purpose of this clinical commentary is to provide a rationale for the implementation of a biopsychosocial model of knee OA that can aid in more effective research and treatment for the disorder.

Work disability among two cohorts of women with recent-onset rheumatoid arthritis: a survival analysis

OBJECTIVE

To analyze factors associated with leaving employment among women with newly diagnosed rheumatoid arthritis (RA).

METHODS

Women with RA were recruited from a national sample of rheumatologists in 1987 and 1998. Inclusion criteria were RA diagnosis <18 months earlier, age >or=18 years, and no other disabling health condition. The 1987 and 1998 cohorts comprised 48 and 91 women, respectively. Data were collected by telephone for 4 years. Survival analysis was conducted using Kaplan-Meier curves and a proportional hazards generalized linear model to assess whether the time to stopping work differed between the cohorts and to identify baseline predictors and time-varying covariates of leaving work.

RESULTS

Most patients were age <50 years, married, had >12 years of education, and were white. Fifteen patients (31%) in the 1987 cohort and 24 patients (26%) in the 1998 cohort stopped working in the observation periods. Kaplan-Meier survival curves for each cohort were not significantly different. Multivariate analyses demonstrated that married women (P = 0.03) and those with joint deformities (P = 0.00) were more likely to stop working. A significant flares by cohort interaction (P = 0.01) indicated that, in comparison with patients in the 1998 cohort, those in the 1987 cohort with <2 disease flares had the lowest risk of stopping work and those with >or=2 flares had the greatest risk.

CONCLUSION

Unexpectedly, the cumulative rate of stopping work among women in the 1998 study did not differ from that among women diagnosed >16 years earlier. However, disease flares greatly affected employment in the 1987 but not the 1998 cohort, possibly indicating that newer medications were effective in maintaining functional status among those with more severe disease activity, measured by number of flares, in the 1998 group.

Arthritis symptoms, the work environment, and the future: measuring perceived job strain among employed persons with arthritis

OBJECTIVE

To develop a measure of job strain related to differing aspects of working with arthritis and to examine the demographic, illness, work context, and psychosocial variables associated with it.

METHODS

Study participants were 292 employed individuals with osteoarthritis or inflammatory arthritis. Participants were from wave 3 of a 4-wave longitudinal study examining coping and adaptation efforts used to remain employed. Participants completed an interview-administered structured questionnaire, including a Chronic Illness Job Strain Scale (CIJSS) and questions on demographic (e.g., age, sex), illness and disability (e.g., disease type, pain, activity limitations), work context (e.g., job type, job control), and psychosocial variables (e.g., arthritis-work spillover, coworker/managerial support, job perceptions). Principal component analysis and multiple linear regression were used to analyze the data.

RESULTS

A single factor solution emerged for the CIJSS. The scale had an internal reliability of 0.95. Greater job strain was reported for future uncertainty, balancing multiple roles, and difficulties accepting the disease than for current workplace conditions. Participants with inflammatory arthritis, more frequent severe pain, greater workplace activity limitations, fewer hours of work, less coworker support, and greater arthritis-work spillover reported greater job strain.

CONCLUSION

The findings underscore the diverse areas that contribute to perceptions of job strain and suggest that existing models of job strain do not adequately capture the stress experienced by individuals working with chronic illnesses or the factors associated with job strain. Measures similar to the CIJSS can enhance the tools researchers and clinicians have available to examine the impact of arthritis in individuals' lives.

Health status, activity limitations, and disability in work and housework among Latinos and non-Latinos with arthritis: an analysis of national data

OBJECTIVE

To document disparities in health status, activity limitations, and disability in work and housework between Latinos and non-Latino whites with arthritis. We examined whether sociodemographic factors (age, income, and education) account for the disparities between the ethnic groups, and whether comorbid conditions, disease duration, health care utilization, and functional abilities predict health status, activity limitations, and work and housework disability after controlling for sociodemographic variables.

METHODS

We analyzed data from the Condition file of the 1994 National Health Interview Survey on Disability, Phase I.

RESULTS

The risk of worse health, activity limitations, and work and housework disability was >2 times greater among Latinos compared with non-Latino whites. In the regression models accounting for potential confounders, Latino ethnicity remained significantly associated with poorer health status, but not activity limitations or disability in work or housekeeping. Of the socioeconomic status variables, education had a significant protective effect on work disability and health status. Comorbid conditions and health care utilization increased the likelihood of worse health, activity limitations, and work disability. Limitations in physical function were associated with poorer health and disability in work and homemaking.

CONCLUSION

Social status differences between Latinos and non-Latinos may account for disparities in activity limitations and disability in work and housework. Education may provide various health benefits, including access to a range of occupations that do not require physical demands. The findings help to address the great gap in knowledge concerning factors related to the health and disability status of Latinos with arthritis.

Profile of arthritis disability: II

OBJECTIVE

Arthritis is the most common chronic condition and the most common cause of disability among older US adults. We studied social participation, disabilities in many life domains, accommodations used (buffers), and accommodations needed (barriers) for US adults with arthritis disability compared with adults with disability from other conditions.

METHODS

The data source is the National Health Interview Survey Disability Supplement Phase Two. Arthritis-disabled individuals named arthritis as the main cause of > or =1 disabilities. Other-disabled individuals named only other conditions as causes of their disabilities. We compared outcomes for the groups, taking sample weights and complex variances into account.

RESULTS

Arthritis-disabled individuals get out and about less often than other-disabled individuals, but they manage to maintain active social ties. They have more disabilities of all types (personal care, household management, physical tasks, transportation, home, work), and the disabilities often cause fatigue, long task time, and pain. Despite this, arthritis-disabled individuals use less personal assistance than other-disabled individuals; they do use more equipment assistance. Arthritis-disabled individuals report more barriers in getting around outside their home and at their workplace.

CONCLUSION

The distinctive profile of arthritis disability includes extensive and uncomfortable disabilities, yet there are active management strategies to handle these disabilities. Problems away from home and at work should inspire engineers and planners to improve public access and equipment for persons with this high-prevalence disability.

Work disability in early rheumatoid arthritis: higher rates but better clinical status in Finland compared with the US

OBJECTIVE

To analyse and compare work disability attributed to rheumatoid arthritis in two cohorts of patients with early disease: one in the US and the other in Finland.

PATIENTS AND METHODS

Two cohorts of patients who were working and aged <65 years at the time of their first symptom of rheumatoid arthritis were studied: 269 patients in Nashville, TN, USA (median age 46 years, 72.5% females), and 364 patients from Jyväskylä, Finland, (median age 47.1 years, 70.9% females). The cohorts were analysed and compared for measures of clinical status and work disability status over a median (interquartile range) of 38.9 months in Nashville and 48.4 months in Jyväskylä.

RESULTS

The probability of working at 36 months was 0.89 (0.84-0.92) for patients from Nashville and 0.84 (0.80-0.88) for patients from Jyväskylä (p = 0.02). These rates were lower than in earlier decades. Patients from Jyväskylä had significantly higher rates of work disability (p = 0.02) than those from Nashville, but better scores for self-report physical function (p<0.001), pain (p<0.001) and global status (p<0.001) at last observation. The likelihood of being disabled from work was 2.6-fold higher in Jyväskylä compared to Nashville (95% confidence interval 1.44 to 4.59, p = 0.001), after adjustment for demographic and disease-specific variables.

CONCLUSION

Rates of work disability in both early rheumatoid arthritis cohorts were improved from earlier decades, but differed significantly in two different social systems. Higher work disability rates with better clinical status was seen in the Finnish early rheumatoid arthritis cohort than in the US cohort.

The Indirect Costs of Arthritis Resulting From Unemployment, Reduced Performance, and Occupational Changes While at Work

OBJECTIVE

The objective of this study was to assess the cost attributable to lost productivity from arthritis and the association between the degree of loss and demographic, disease-related, occupational, and psychosocial variables for people.

METHODS

In a prospective study, 383 employed individuals with arthritis were recruited from southwestern Ontario, Canada. Respondents completed structured questionnaires assessing demographic, disease-related, workplace, and psychosocial variables as well as employment-related transitions at 2 time points 18 months apart. Indirect costs resulting from arthritis-related absences, reduced performance, decreased work hours, job change, and work disability were estimated. A proportional odds model was used to assess the impact of the various variables on lost productivity.

RESULTS

The average cost attributable to arthritis was CAN Dollars 11,553(Dollars CAN = 0.75 Dollars US) per person per year. The largest component of the loss was the result of reduced performance at work, which accounted for 41% (Dollars 4724) of the total loss. This was followed by wage loss resulting from stopping working or changing jobs, which comprised 37% (Dollars 4309) of the total. Another 12% (Dollars 1398) and 10% (Dollars 1121) of the loss were the result of the decrease in hours of work and absenteeism, respectively. Four variables were associated with the productivity loss: greater symptom severity (odds ratio [OR] = 1.11), low or medium control over the work schedule (OR = 0.55 and 0.60, respectively), greater workspace limitation (OR = 1.10), and higher depression (OR = 1.04).

CONCLUSIONS

Indirect arthritis-related costs are substantial. Our results show that not only the disease itself, but also psychosocial and work-related factors affect the magnitude of the costs.

Work disability in rheumatoid arthritis is predicted by physical and psychological health status: a 7-year study from the Oslo RA register

OBJECTIVE

To explore the prevalence of work disability (WD) and to identify bio-psychological factors that predicts future WD in rheumatoid arthritis (RA) over a 7-year period.

METHODS

Patients were selected from the Oslo RA register. The prevalence of WD was studied cross-sectionally among respondents <67 years (n = 526) in a postal survey. Mean age (SD) was 51.1 (11.9) years, mean disease duration 11.3 (9.4) years, and 49% of patients were RF-positive. The patients studied for predictive factors for WD were respondents in postal surveys both at baseline and at the 7-year follow-up, in work at baseline and still in working age (<67 years) at follow-up (n = 159). Mean age at baseline (SD) was 44.5 (9.7) years, mean disease duration 8.4 (6.6) years, mean years of formal education 12.7 (3.1) years, 48% were RF-positive. Assessments included socio-demographic variables and health status measures (MHAQ, AIMS2, SF-36, fatigue and pain on VAS 0-100 mm, self efficacy, and RAI as a measure for helplessness).

RESULTS

Among the 526 respondents at baseline <67 years, the prevalence of WD was 40%. A high level of education was a predictor of reduced risk of work disability [odds ratio (OR) = 0.4, 95% confidence interval (CI) 0.1; 0.9], while female gender (OR 3.0, 95% CI 1.1; 8.0), physical disability (MHAQ-score) (OR = 3.9, 95% CI 1.2; 12.5) and helplessness over median RAI-score (OR = 3.0, 95% CI 1.4; 6.7) were independent predictors of increased risk for new work disability over 7 years.

CONCLUSION

Physical disability, increased helplessness, low formal education, and female gender were found to be independent risk factors for new work disability over the 7-year study period.

Reexamining the arthritis-employment interface: Perceptions of arthritis-work spillover among employed adults

OBJECTIVE

To examine employed individuals' perceptions of arthritis-work spillover (AWS), the reciprocal influence of arthritis on work and work on arthritis, and the demographic, illness, and work context factors associated with AWS.

METHODS

The study group comprised 492 employed individuals with osteoarthritis or inflammatory arthritis. Participants completed an interview-administered, structured questionnaire assessing AWS, demographic (e.g., age, sex), illness (e.g., disease type, pain, activity limitations), and work context (e.g., workplace control, hours of work) variables. Principal components analysis, reliability analysis, and multiple linear regression were used to analyze the data.

RESULTS

A single factor solution emerged for AWS. The scale had an internal reliability of 0.88. Respondents were more likely to report that work interfered with caring for their arthritis than they were to report that their disease affected their work performance. Younger respondents, those with more fatigue and workplace activity limitations, and those working in trades and transportation reported more AWS. Individuals with more control over their work schedules reported less AWS.

CONCLUSION

The results of this study extend research on arthritis by reexamining the interface between arthritis and employment. This study introduces a new measure of AWS that enhances the range of tools available to researchers and clinicians examining the impact of arthritis in individuals' lives.

Systematic review of studies of productivity loss due to rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, debilitating disease with a significant impact on workplace productivity.

AIM

To perform a systematic review of studies of the relationship between RA and reduced workplace productivity.

METHODS

Screening of 307 titles identified in bibliographic database searches resulted in 38 articles subject to systematic review. Productivity loss was expressed by three different measures: work disability, work loss (synonymous with absenteeism or short-term sick leave) and work limitation (reduction in productivity while present at work).

RESULTS

A median of 66% (range 36-84%) of employed RA subjects experienced work loss due to RA in the previous 12 months, for a median duration of 39 days (range 7-84 days). The times from RA diagnosis until a 50% probability of being work disabled varied from 4.5 to 22 years. In inception cohort studies, the baseline variables consistently predictive of subsequent work disability were a physically demanding work type, more severe RA and older age.

CONCLUSIONS

RA-related work-disability rates were similar in the USA and European countries. An apparent decrease in the prevalence of RA-related work disability since the 1970s may be related to a decrease in physically demanding work rather than to epidemiologic changes in RA. The majority of the literature addresses permanent disability and temporary work loss; none of the studies reviewed reported the effect of RA on presenteeism, i.e. work limitation from the employer perspective, and there are few published studies of the effectiveness of disease-modifying anti-rheumatic drugs in reducing work-related productivity loss.

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.

Arthritis and employment: An examination of behavioral coping efforts to manage workplace activity limitations

OBJECTIVE

To examine ways in which individuals with arthritis manage their employment and health by focusing on the type and determinants of diverse behavioral coping strategies used to manage activity limitations, and to examine the relationship between coping behaviors and participation in employment.

METHODS

The study group comprised 492 patients with osteoarthritis or rheumatoid arthritis. All participants were employed, and all participants were administered an in-depth, structured questionnaire. The study used an inductive approach and distinguished among 4 categories of coping behaviors as follows: adjustments to time spent on activities; receipt of help; modification of behaviors; and anticipatory coping.

RESULTS

Fewer coping behaviors were reported at the workplace than outside of the workplace. Anticipatory coping was used most often in the workplace. Workplace activity limitations were related to increased reports of all types of coping. Women, those with more joints affected, and people expecting to remain employed reported more anticipatory coping. Expectations of continued employment were also related to modifications of activities, as was longer disease duration and discussing arthritis with one's employer. Help from others was associated with talking to an employer and positive job perceptions. Compared with work, reports of a greater number of coping behaviors used at home were associated with changes in overall work participation (e.g., absenteeism).

CONCLUSION

These results expand our understanding of the experience of having a chronic illness and working and highlight the ways in which people accommodate to workplace limitations by using a variety of different behavioral coping efforts to remain employed.

Predictive factors of work disability in rheumatoid arthritis: a systematic literature review

BACKGROUND

Work disability-a common outcome of rheumatoid arthritis (RA)-is a societal (for example, financial costs) and individual problem (for example, loss of status, income, social support, and distraction from pain and distress). Until now, factors that predict work disability in RA have not been systematically reviewed.

OBJECTIVE

To determine predictive factors of work disability in RA as reported in the literature.

METHODS

A systematic literature search in Cinahl (1988-2004), Embase (1988-2004), and Medline (1989-2004) was followed by the application of two sets of criteria related to: (a) methodological quality, and (b) measurement of the predictive factor. Based on the quality and the consistency of the findings, a rating system was used to assess the level of evidence for each predictive factor.

RESULTS

Nineteen publications (17 cohorts) were identified, of which 13 met the general methodological quality criteria. Results provided strong evidence that physical job demands, low functional capacity, old age, and low education predict work disability in RA. Remarkably, biomedical variables did not consistently predict work disability. Moreover, owing to the lack of high quality studies no evidence was found for personal factors such as coping style, and work environmental factors such as work autonomy, support, work adjustments that are presumed crucial in the work disablement process.

CONCLUSIONS

The results indicate that work disability in RA is a biopsychosocially determined misfit between individual capability and work demands.

Identification of modifiable work-related factors that influence the risk of work disability in rheumatoid arthritis

OBJECTIVE

To define work-related factors associated with increased risk of work disability (WD) in people with rheumatoid arthritis (RA).

METHODS

Questionnaires were mailed to all RA patients who used a province-wide arthritis treatment program between 1991 and 1998 (n = 1,824). The association between risk factors and WD (defined as no paid work due to RA for at least 6 months) was assessed using multiple logistic regression analysis, controlling for significant sociodemographic and disease-related variables.

RESULTS

Of the original 1,824 patients, 581 were eligible and responded to the questionnaire. Work survival analysis revealed a steady rate of WD starting early, with 7.5%, 18%, and 27% work disabled at 1, 5, and 10 years, respectively. Significant determinants in multiple logistic regression were physical function (Health Assessment Questionnaire), pain (visual analog scale), and 6 work-related factors: self employment, workstation modification, work importance, family support toward employment, commuting difficulty, and comfort telling coworkers about RA.

CONCLUSION

Work disability occurs early in RA. Novel work-related factors were identified, which are potentially modifiable, to help RA patients stay employed.

Careers and mortality in France: evidence on how far occupational mobility predicts differentiated risks

This new study goes beyond the well-established correlation between mortality differentials and occupational status, to focus on the impact of professional careers on mortality risk. It shows heterogeneity in the mortality risks within occupational classes, strongly related to the type of occupational moves experienced. The occupational data are taken from the French longitudinal census sample-using 1968 and 1975 census records-and mortality risks are estimated over the 1975-1980 period, for both occupational classes and pathways between classes. Results show a close relationship between occupational mobility and mortality. For men, favorable occupational moves-e.g. from clerks to upper class-put them less at risk of mortality than their counterparts who remained in their class. An inverse relationship is found for unfavorable moves. In most cases, the mortality risks of the movers are in between the risks in the class left and in the class joined. Similar patterns apply to specific groups of women only (upper classes, manual workers, clerks) for which occupational moves are probably driven, as for most men, by mortality related determinants (level of education, qualifications, health, etc.). The findings strongly support the use of a dynamic approach, based on individuals' experiences, to improve our understanding of mortality differentials.

Association between etanercept use and employment outcomes among patients with rheumatoid arthritis

OBJECTIVE

To assess the association between use of etanercept and employment outcomes among patients with rheumatoid arthritis (RA).

METHODS

In 1999, 497 RA patients of working ages (18-64 years) reported their employment status in the year of diagnosis and as of the study year, in structured telephone interviews. Of these, 238 had been in clinical trials of etanercept and were currently taking that medication, while 259 were members of an observational study and were not taking etanercept. We used regression techniques to estimate whether employment outcomes in 1999 (employed versus not and, among the employed, hours of work per week, weeks of work per year, and hours of work per year) among the 379 of the 497 patients who were employed at the time of diagnosis were associated with etanercept use, with and without adjustment for demographic characteristics, RA status, overall health status, and the nature of the job held at the time of diagnosis.

RESULTS

At the time of diagnosis, 75% of RA patients from the observational study who did not take etanercept and 77% of those who did take the medication were employed. By 1999, among those employed at diagnosis, 55% of the former group and 71% of the latter were employed (difference 16 percentage points). After adjustment for demographics, overall health status, duration of RA, RA status, and occupation and industry, the difference widened to 20 percentage points. Among all who were employed at the time of diagnosis, those from the etanercept clinical trials worked an average of 5.4 more hours per week in 1999; after adjustment, the etanercept group worked 7.4 more hours per week.

CONCLUSION

Among all persons who were employed at the time of RA diagnosis, having been in the etanercept clinical trials was associated with higher employment rates in 1999 and a greater number of hours per week of work in that year, suggesting that a randomized trial to establish the relationship between treatment and employment outcomes is now warranted.

Vocational rehabilitation in patients with chronic rheumatic diseases: a systematic literature review

OBJECTIVE

To describe the effectiveness of vocational rehabilitation programs for patients with chronic rheumatic diseases by means of a systematic review of the literature.

METHODS

Data were obtained by a computer-aided and manual search of the literature from 1980 until May 2001. Vocational rehabilitation programs had to be clearly defined interventions specifically aimed at having patients with rheumatic diseases reenter or remain in the work force. The vocational rehabilitation programs had to be executed by one or more health professionals. Outcome of the intervention had to be described in terms of vocational status (work disability, sick leave, job modification, paid occupation, retraining).

RESULTS

Six studies were identified. All were uncontrolled studies. Follow-up periods ranged 2-84 months. Five of six vocational rehabilitation programs consisted of multidisciplinary intervention and 15% to 69% of the patients successfully returned to work.

CONCLUSIONS

Although 5 of 6 studies showed a marked positive effect of vocational rehabilitation on work status, proof of the benefit of these interventions is limited, mainly due to methodologic differences and shortcomings.

RELEVANCE

Work disability is a major consequence of the disease in patients with rheumatic conditions. More and more attention is being paid to preventing disability and promoting return to work. Knowledge regarding the effectiveness of vocational rehabilitation programs is insufficient. Semin Arthritis Rheum 32:196-203.

Negative social perception of hypothetical workers with rheumatoid arthritis

In the present study, 340 college subjects evaluated the job performance of hypothetical workers of varying health status, to test the hypothesis that workers with rheumatoid arthritis (RA) are more negatively perceived than other workers (paraplegic, healthy) despite equivalence in age, sex, education, job history, and time off from work for medical reasons. Results indicated that workers with RA are perceived as having significantly poorer interpersonal job skills and are deserving of significantly poorer scores for overall job performance, although no differences were obtained in the ratings of their job commitment or job expertise. The suggestion is made that an unfavorable social reaction to RA patients in the workplace is one factor that impairs the development of social support for these patients at work and contributes to their inflated disability rate.

Women and arthritis: burden, impact and prevention programs

OBJECTIVES

To characterize the public health burden and impact of arthritis among women, document the growing interest in addressing arthritis as a public health problem, and review new national (Centers for Disease Control and Prevention [CDC]) and state arthritis programs.

RESULTS

Arthritis and other rheumatic diseases are a major public health problem, affecting nearly 27 million women in 1997 and accounting for 23.9 million ambulatory medical care visits and 451,000 hospitalizations among women in that year. Arthritis is also the leading cause of disability and is associated with considerable functional limitations. The 1999 National Arthritis Action Plan: A Public Health Strategy prompted first-time congressional funding to the CDC to monitor the burden of arthritis and to establish state arthritis prevention programs through cooperative agreements. The CDC's Arthritis Program also used this funding to build the public health science base, develop national health communications campaigns, foster partnerships, and initiate health systems change.

CONCLUSIONS

Arthritis in general and selected types, such as rheumatoid arthritis, systemic lupus erythmatosus (SLE), and fibromyalgia, disproportionately affect women. The CDC, state health departments, and their partners are working toward improving the quality of life for women affected by arthritis. Effective, evidence-based interventions, such as self-management education and physical activity programs, are currently available and can reduce pain, improve function, and delay disability, but they remain underused. Future research should focus on improving earlier diagnosis and increasing access to effective interventions.

Functional disability predicts total costs in patients with ankylosing spondylitis

OBJECTIVE

To describe the composition and distribution of total costs of ankylosing spondylitis (AS), and to identify predictors of high total costs among patients with AS.

METHODS

In a prospective longitudinal study, 241 patients with AS reported information on health status, health care utilization, treatments, and work limitations on biannually mailed questionnaires. Annual direct costs were estimated on the basis of reported ambulatory care visits, hospitalizations, diagnostic tests, medications, assistive devices, nonallopathic treatments, travel to visits, and paid household help. Indirect costs were estimated from the number of work days missed or, for retirees and homemakers, the number of days of activity limitation. A similar analysis was performed for cumulative costs over 5 years in a subset of 111 patients.

RESULTS

Annual total costs averaged $6,720 (in 1999 US dollars; median $1,495). Indirect costs comprised 73.6% and direct costs comprised 26.4% of total costs, although only 95 patients (39%) contributed to the indirect costs. Functional disability was the most important predictor of high total costs. The likelihood of having high (>$10,000) total costs increased by a factor of 3 with each 1-point increase in the Health Assessment Questionnaire disability index modified for the spondylarthropathies (HAQ-S; range 0-3). Results were similar in the subgroup of 111 patients who were followed up for 5 years, among whom the likelihood of high cumulative total costs (>$50,000 over 5 years) increased by >6 times with each 1-point increase in the HAQ-S.

CONCLUSION

Functional disability is the most important predictor of total costs in patients with AS. Interventions that maintain or improve patients' functional ability will likely have the greatest potential to decrease the costs of AS.

Work factors and behavioural coping in relation to withdrawal from the labour force in patients with rheumatoid arthritis

OBJECTIVE

To assess separate and combined effects of work factors and behavioural coping in relation to withdrawal from the labour force among patients with rheumatoid arthritis (RA).

METHODS

A cross sectional study was conducted in a Dutch nationwide random sample of 720 patients with RA. Information about work factors and behavioural coping was collected by a self-administered postal questionnaire. A broad variety of work factors and coping styles were evaluated separately and in combination using multivariate logistic regression analyses, controlling for sociodemographic and disease related variables. Attributable and preventable fractions were calculated from the combined analyses to assess the relative importance of the contributing factors.

RESULTS

Additional job training, equal career opportunities, letting the disease influence the choice of the current job position, and informing colleagues about having the disease were negatively associated with withdrawal from the labour force. The most relevant factor in terms of decreasing the risk was adjusting job demands which accounted for 63% of the patients still in the labour force. Decreasing activities and diverting attention in order to cope with pain, and pacing in order to cope with limitations were the coping styles which were positively associated with withdrawal from the labour force. The most relevant factor in terms of increasing the risk of withdrawal was pacing which accounted for 67% of the withdrawals.

CONCLUSION

Work factors are potentially important modifiable risk factors for withdrawal from the labour force in patients with RA. Behavioural coping is also relevant.

On the organization of an early arthritis clinic

Early active treatment with disease-modifying anti-rheumatic drugs has become standard management for patients with recent-onset rheumatoid arthritis. A number of questions, however, remain unresolved for practising clinicians, for example how early and how actively to treat and what the treatment goals should be. This chapter summarizes some recent data that have added important empirical evidence on these issues. It has thus been demonstrated that the formal organization of an early arthritis clinic shortens the referral time from primary care, that a delay in the institution of disease-modifying drug treatment leads to decreased long-term function and that early active treatment with pharmacotherapy as well as team-based care may increase occupational capacity. It is argued that adopting a day care approach in the initial encounter with specialist care may increase the possibility for patients actively to understand the disease and their own potentials to diminish and cope with its effects. The further development of care for early arthritis patients with new, potentially efficient but also expensive drugs will increase the requirement for a structured documentation of outcomes, systems for such documentation being discussed in the chapter.

Employment, work disability, and work days lost in patients with ankylosing spondylitis: a cross sectional study of Dutch patients

OBJECTIVE

To evaluate employment status, work disability, and work days lost in patients with ankylosing spondylitis (AS).

METHODS

A questionnaire was sent to 709 patients with AS aged 16-60. The results of 658 of the patients could be analysed.

RESULTS

After adjustment for age, labour force participation was decreased by 15.4% in male patients and 5.2% in female patients compared with the general Dutch population. Work disability (all causes) was 15.7% and 16.9% higher than expected in the general population for male and female patients respectively. In particular, the proportion of those with a partial work disability pension was increased. Patients with a paid job lost 5.0% of work days as the result of having AS, accounting for a mean of 10.1 days of sick leave due to AS per patient per year in addition to the national average of 12.3 unspecified days of sick leave.

CONCLUSION

This study on work status in AS provides data adjusted for age and sex, and the differences from the reference population were significant. The impact of AS on employment and work disability is considerable. Work status in patients with AS needs more attention as an outcome measure in future research.

Update on work disability in rheumatic diseases

Two recent studies suggest the prevalence of rheumatic condition-related work disability is considerably lower than was suggested in previous studies. However, the samples in the recent studies did not include older workers and included persons who gained employment after disease onset. In other recent studies, the rate of work disability among persons employed at disease onset is still high; a fair amount of work disability occurs in the early years of disease. There is no clear evidence yet that treatment improvements have altered the rates of work disability. Because work characteristics, like level of physical demand, influence risk for work disability and are potentially amenable, other interventions are needed to reduce rheumatic disease-associated work disability. Accommodation provided to alleviate problems in doing work and outside of work activities is the most promising intervention, followed by job/career change. Assessment tools are just now becoming available to help clinicians identify patients in need of assistance.

The prevalence and impact of accommodations on the employment of persons 51-61 years of age with musculoskeletal conditions

OBJECTIVE

To provide estimates of the frequency with which persons 51 to 61 years of age with musculoskeletal conditions receive workplace accommodations from their employers and to determine if the receipt of such accommodations is associated with higher rates of employment two years later.

METHODS

The estimates derive from the Health and Retirement Survey, a national probability sample of 8,781 respondents who were interviewed both in 1992 and 1994 and who were between the ages of 51 and 61 years, of whom 5,495 reported one or more musculoskeletal conditions. We tabulated the frequency of accommodations provided in 1992 and then estimated the impact of accommodations and demographic and medical characteristics on 1994 employment status, using logistic regression.

RESULTS

In 1992, about 14.40 million persons aged 51-61 years reported a musculoskeletal condition. Of these, 1.32 million (9.2%) reported a disability and were employed, the target population for accommodations. Overall, fewer than 1 in 5 persons with musculoskeletal conditions who had a disability and were employed indicated that they had received any form of accommodation on their current jobs. Although no form of accommodation was reported with great frequency, the most commonly used ones included getting someone to help do one's job (12.1%), scheduling more breaks during the work day (9.5%), changing the time that the work day started and stopped (6.3%), having a shorter work day (5.6%), getting special equipment (5.3%), and changing the work tasks (5.3%). Persons with one or more accommodations in 1992, however, were no more likely to be working in 1994 than those with none. Only one specific accommodation--getting someone to help do one's job--was associated with a higher rate of employment in 1994.

CONCLUSIONS

Receipt of employment accommodations occurred infrequently, and was not generally associated with an improvement in the employment rate of persons with musculoskeletal conditions and disabilities.

Rheumatoid arthritis, disability and the workplace

Rheumatoid arthritis is a common cause of disability worldwide. The nature of the disability impacts on all areas of life. This chapter focuses on the nature of the disability of rheumatoid arthritis with emphasis on work disability. The various approaches for minimising the disability and rehabilitating those with disability are discussed. The tools for the assessment of disability are described and their strengths and limitations outlined.