Working with rheumatic and musculoskeletal diseases (RMDs)

Scope of the article

This article covers any problem that affects muscles, bones or joints and impacts on a person’s ability to work.  It may be caused or aggravated by work and then is often called a ‘work-related musculoskeletal disorder (work-related MSD)’.   However, there are many problems that affect the muscles, bones or joints that are often long-term and can impact on work or be aggravated by work, but there is not a clear causative link.  These are commonly called rheumatic and musculoskeletal diseases (RMDs) or musculoskeletal conditions in health care.  In this article, they are referred to as RMDs.

Impact of RMDs on work

• RMDs^[1] affect 1 in 4 persons (more than 120 million people in the EU) and account for almost 30% of all disabilities.
• The total cost of work-related RMDs is estimated at over € 163bn, including productivity loss and turnover costs for employers (33%), workers’ income and health-related quality of life losses (65%).
• Estimated total cost of work-related MSD can be as high as 2% of the Gross national product of countries in Europe.

Why musculoskeletal health is important

Musculoskeletal (MSK) health means working joints and muscles and strong bones which give us mobility and dexterity, and the ability to do in comfort, the physical tasks of everyday life and to enjoy our lives through work, rest and play.  Being physically active and doing exercise keeps us healthy, but we cannot do this without being able to move freely without pain.  This is increasingly important as we are all living longer and need to work longer, with retirement ages being increased. If we can maintain our musculoskeletal health then we can continue in work, we can maintain our economic independence and we can go into retirement with active bodies that allow us to enjoy those years beyond work.

What are rheumatic and musculoskeletal diseases (RMDs)?

Most of us get aches and pains or stiffness at some time, particularly as we get older, but can relate to injuries or illnesses at any age. There is a wide variety of problems that affect the musculoskeletal system: bones, joints, muscles, tendons and the tissues that connect them. Often the problem lasts for a short time and recovery will happen with little need for treatment, but sometimes they last longer and are then called chronic rheumatic and musculoskeletal diseases (RMDs). If they are caused or aggravated by work they are often called work-related musculoskeletal disorders (work-related MSDs).

There are a range of causes, including inflammatory diseases, ageing, injuries, congenital and developmental.  They are also related to obesity and a lack of physical activity.  Smoking and excess alcohol consumption can also affect musculoskeletal health.  However, sometimes the precise cause of musculoskeletal pain remains unclear and then it is described for what it is, such as shoulder pain or back pain.

Problems that affect musculoskeletal health and typically cause pain and impaired function include:

• Joint conditions—for example, rheumatoid arthritis (RA), osteoarthritis (OA), psoriatic arthritis (PsA), gout, ankylosing spondylitis (AS)
• Bone conditions—for example, osteoporosis and associated fragility fractures, osteomalacia and rickets
• Spinal disorders—for example, low back pain and disc disorders
• Regional and widespread pain disorders – for example, frozen shoulder, tennis elbow, fibromyalgia
• Musculoskeletal injuries—for example, strains and sprains often related to occupation or sports, high-energy limb and spinal fractures
• Genetic, congenital and developmental childhood disorders – for example scoliosis
• Multisystem inflammatory diseases which commonly have musculoskeletal manifestations such as connective tissue diseases and vasculitis – for example, systemic lupus erythematosus

What impact do RMDs have on individuals – pain, fatigue, function?

RMDs affect people in many ways.  They cause pain affecting arms, legs, neck or back – not always severe but often persistent, nagging and wearing.  It may vary, often unpredictably, but may be worse with or after use.  There may be swelling of joints but often there is nothing to see, as the pain is not visible this can be frustrating to the sufferer and cause disbelief by those around them.  Pain can make it difficult to do the same activities repeatedly.  There is often stiffness, taking a while to get moving. Sleep can be disturbed, and then it may be more difficult to ignore pain.  People can become tired and fatigued particularly if an inflammatory disease or if sleep is disturbed. If the person is stressed, anxious or depressed because of the pain or for other reasons, this also makes it harder to ignore pain and the RMD has more of an impact on their lives.  People with an RMD also become fearful of the future, in relation to whether their limitations will worsen or if will they lose their job. There is a close interaction between the mind and musculoskeletal pain.

The effects of pain are pervasive as we need to move for virtually all activities.  RMDs can limit everyday chores, work and leisure activities.  They can stop the person getting out and about and they can become socially isolated.  They affect a person’s general fitness and they are less healthy.

How do RMDs affect people’s ability to work? – case studies

RMDs have a pervasive affect.  Most tasks we do at home, at work and when having fun need us to be able to move in comfort - to have mobility and dexterity.  People with chronic RMDs learn to work around their problems whether at home or in the workplace.  They are productive and try to avoid missing work and often do not disclose the challenges they have if they think they are in control of them. But then, if symptoms worsen, work can become challenging.  Earlier disclosure and reasonable adjustments can prevent this worsening of symptoms leading to work loss. Below are two case examples.

Key principles for addressing MSK health in the workplace and enabling people to work despite RMDs

People with RMDs need to be enabled to help themselves and minimise, manage and work around their problems.  This needs a comprehensive approach of understanding their needs through open conversations, understanding what they can do and what they should avoid doing; this should be guided by medical advice.  Most people with RMDs are able to undertake work in some form, but there is a need for flexibility to find ways to overcome the challenges that RMDs bring.  The gain is that the person can continue to work, which is both good for the employer and is also good for the employee.

Addressing MSK health in a workplace means recognising the importance of MSK problems and knowing the risks and the problems present, in particular for employees who may already have some MSK problem and reducing exposure to those risks.  It means promoting MSK health through lifestyle changes such as encouraging physical activity, avoiding sedentary behaviours and enabling healthy eating.  For people who have an RMD it means helping them to manage their own health, supporting early action when a problem arises and enabling them to stay in work. Managers and employees need to be trained to understand MSK health, how RMDs can affect it and ways of dealing with challenges to enable an employee with an RMD to remain in work and productive.

The ultimate goal is to provide a workplace that:

• takes preventative action,
• encourages early intervention for any MSK problem
• makes reasonable adjustments to enable people to work despite their RMD
• accommodates effective rehabilitation and return to work plans.

How can MSK health be promoted?

• Good MSK health is not only about building and maintaining healthy bones, muscles and joints, but it is also about avoiding doing harm or damage.
• People need to avoid risks where possible and not put themselves at unnecessary risk of injury by following safe techniques, safe practices, using the right equipment and not taking short cuts.
• Avoid prolonged static postures, sedentary behaviour, or repetitive movements.
• Keep physically active to remain fit, maintain an ideal weight, have a balanced diet with calcium and fish oils and avoid smoking or excessive alcohol consumption.
• Work processes need to minimize these risks and recognize that employees with RMDs may be more susceptible.

How can people who develop an RMD be helped?

Early intervention

The sooner a problem is managed, the less likely it will be to cause loss of work in the longer term.  Often simple measures can be taken to enable the employee to continue to work. This means encouraging and enabling employees to talk about an MSK problem as soon as it arises and acting on the outcome of that conversation.

Open conversations

• People do not like speaking about their health and especially about their physical challenges in doing their work.  They often think that their manager will not be supportive.  They learn to work around their RMD when they are in control of their symptoms.  They take sick leave when they can no longer manage, whereas with some early adjustments to their work and the medical management of their RMD this may have enabled them to stay in work.
• An open, positive culture is essential to managing MSK problems. A workplace with a positive culture enables an employee to look after their own MSK health, say when they are struggling and receive early treatment and support to enable them to continue to work.
• Employees should be made aware that employers cannot take action to help make reasonable adjustments or prevent any workplace harm if they are not aware that they are struggling because of their MSK problem.  Employees need to tell their employer about their arthritis, joint pain or related condition and difficulties they are having in the workplace at an early stage. This could include the following:
  • what condition they have
  • the symptoms they are experiencing
  • if the symptoms vary from day to day and how it can make them feel on a bad day
  • the effects of medication
  • what tasks they find challenging and may need some help with
  • what useful support might consist of and how it would enable them to do their job
  • Employees should be made aware that their employer encourages early reporting at work, will try and make simple adjustments and suggest the employee seeks healthcare advice as soon as possible.

Simple adjustments in the workplace

• Most employees with an RMD are able to continue in work, providing there is some allowance for their symptoms problem.  Continuing in work within their abilities will not cause more damage or a worse health outcome in the long-term. In general, being in work is good for mental and physical health.
• The employees needs will become clearer through good communication.  Small changes can be effective in enabling them to work, despite their condition.  Employees need the opportunity to find ways around their problems in the workplace as they do outside work.  Their ability to find solutions can also be supported by advice that is available from the public and voluntary sectors.
• Line managers and co-workers need to understand and pre-empt difficulties the worker may have as employees do not want to keep saying they cannot do something.

Early access to advice

• The sooner an MSK problem is managed, the less it will impact on the employee and their work.  People usually interpret pain as a warning to avoid movement but often keeping mobile is the best management.  If someone has a persistent MSK problem that is affecting their work, then they should seek medical advice.
• Medical advice, if shared with permission, should enable the employer to know what support the employee needs, to provide reasonable adjustment and adaptation and to provide individual support related to their specific problem, which helps employees to work to their potential.

How can people with an established RMD be helped?

People with chronic RMDs and those around them often think they will have to give up their work; this is not true.  An employee with an RMD can be enabled to participate in work even with an ongoing problem through:

• reasonable adjustments
• supporting self-management and sign posting to knowledge and support
• providing individual support

Reasonable adjustments

Reasonable adjustments should be made to an employee’s work if the problem is having a significant impact on their work.  This can be guided by professional occupational health advice. Reasonable adjustments can include:

• Changes to job duties and tasks:
  • changing or modifying the tasks which are part of the job
  • flexibility in practices, roles and responsibilities
  • variability in tasks
  • swapping certain tasks with colleagues
  • ensuring good ergonomics in all tasks
  • reducing or avoiding activities which are difficult or worsen symptoms (e.g. stairs, prolonged standing or sitting and repetitive activities)
  • controlling pace of work

• Equipment and workplace adaptation:
  • providing ergonomically designed or special equipment (e.g. optimising work station, suitable office chair, back rest and/or foot support)
  • using equipment or technology that could make the tasks easier

• Working patterns:
  • altering work patterns/hours
  • ability to take breaks
  • flexibility in working hours as  symptoms of arthritis and related conditions are often worse in the morning, offering flexible hours so that the working day starts and finishes later
  • working from home, for at least part of the week. With advances in modern technology and a growing appreciation of the need for employers to respect people's work/life balance, more people are adopting flexible working arrangements, including working from home.

• Support:
  • allowing time off to attend medical appointments
  • help with travel to and from work
  • opportunities to plan future career or make career changes

The employee’s needs must be reassessed as conditions change and can make new aspects of working life difficult.

Self-management

Helping employees to manage their own health problems, or self-management, is an important approach to be used in conjunction with any support provided by the employer or healthcare professionals. Self-management can include the employee describing which actions in the workplace help with the management of their condition.  It can also include being aware of overall general health and levels of physical activity, finding strategies to manage pain and fatigue, learning how to communicate with friends, family and work colleagues to increase their understanding of the physical and psycho-social impact of the condition, and feeling supported. It includes having appointments during working time with medical professionals to ensure they are getting appropriate treatment.  Self-management can also include setting goals to achieve changes in behaviour that may help their symptoms and quality of life.

Self-management can be taught and there are a number of courses suitable for people with MSK problems that are delivered face-to-face or online, often accessible through patient organisations for people with RMDs.  An employee with a chronic RMD needs time and the opportunity to fulfil self-management of their condition.

Providing individual support to enable staying in work

Enabling an employee to stay in work despite an RMD and the physical challenge of a painful and limiting condition requires a joined-up approach that involves the employee, their healthcare team, and their line manager with the common goal of helping them to stay at work and working within their abilities.

The support an employer can offer to enable an employee with an RMD to stay in work depends on the nature of their problem and what is feasible for the business. Support can be provided directly by the employer but there is also support available from the public and voluntary sectors.

The healthcare team needs to give advice on what tasks are appropriate for the employee and what should be avoided.

Line managers have a crucial role to play in enabling that advice is followed; providing the employer’s policies support it.  The line managers knowledge and commitment are central.

The employee with an RMD needs to maintain a positive attitude about work and staying in work or returning to work despite their problem. They have to deal with the physical and psychological factors related to their condition that challenge their ability to work. Physical barriers are the practical challenges associated with undertaking work-related activities when one has a painful and limiting condition. Psychological barriers are associated with acceptance of having a limiting condition and the need to work around it, frustration and fear around not fulfilling work tasks, anxiety and low mood as a result of pain, fear of the future, and concern that continuing to work may cause more problems and long-term damage.

The employee’s needs will become clearer through good communication.  Suggested questions for the employer to consider to enable them to accommodate an employee with a chronic RMD:

• What limitations is the employee with an RMD experiencing?
• How do these limitations affect the employee and the employee’s ability to perform their work?
• What specific work tasks are problematic as a result of these limitations?
• What adjustments are available to reduce or eliminate these problems now and in the future?
• Discuss with the employee about possible adjustments. Once adjustments have been made, review with the employee and determine if any further adjustments are needed.
• Ensure supervisory personnel and colleagues understand the challenges of RMDs.

The employer may need to know, with permission of the employee, whether the problem is likely to recover, persist or be intermittent to be able to plan for the future.

Summary

Employers can help in a number of ways:

• assess and reduce the risk as far as is reasonably practical to make sure that the workplace is safe, and also designed to promote good musculoskeletal health, beyond their legal responsibilities.
• make adjustments to support employees who have RMDs to help them remain in work.
• support an employee who is absent through a chronic RMD to help them back to work.
• take a proactive approach by supporting employees to lead healthier lifestyles that will reduce the risk of musculoskeletal problems in later life (stop smoking, healthier diets, or enabling staff to have mini-breaks)

Sources of further information and advice

• Continuing to work with arthritis, Verywell Health, USA https://www.verywellhealth.com/continuing-to-work-with-arthritis-189699
• Conversation starters for workplace discussions about MSDs (includes annexes with advice for individual workers and employers on how to have a conversation about an MSD health problem), EU-OSHA https://osha.europa.eu/en/tools-and-publications/publications/conversation-starters-workplace-discussions-about/view
• Employer supports improve function and productivity of workers with arthritis, Institute for Work and Health, Canada https://www.iwh.on.ca/newsletters/at-work/79/employer-supports-improve-function-and-productivity-of-workers-with-arthritis
• Finding a job and working with arthritis, Arthritis Foundation, USA https://www.arthritis.org/living-with-arthritis/life-stages/work/workforce-ready.php<
• Fit for work, Arthritis Ireland https://www.arthritisireland.ie/go/fit_for_work

• How can I get the right support?, Versus Arthritis, UK Joint health at work – why we should care?, The Arthritis Society, Canada [https://education.arthritis.ca/jointhealthatworkwhyweshouldcare.aspx
• Musculoskeletal health in the workplace: a toolkit for employers, Business in the Community/Public Health England, UK https://wellbeing.bitc.org.uk/sites/default/files/business_in_the_community_musculoskeletal_toolkit.pdf
• Working through arthritis, IOSH Magazine, UK https://www.ioshmagazine.com/article/working-through-arthritis
• Working with arthritis, Safety + Health magazine of the National Safety Council, USA https://www.safetyandhealthmagazine.com/articles/13512-working-with-arthritis
• Working with arthritis, Safety + Health magazine of the National Safety Council, USA https://www.safetyandhealthmagazine.com/articles/16725-working-with-arthritis