Work disability is a major burden of arthritis diseases. Among US citizens with arthritis and activity limitation, there was an 11% drop off in labor force participation in 1970–1987 National Health Interview Survey data (1), and among Canadians with arthritis in 1994 work life expectancy was reduced substantially compared with the general population (2). The costs of arthritis-related work disability to society are substantial, amounting to $49.6 billion dollars in the US in 1992 (3), and from the perspective of affected individuals, work disability reduces income substantially (4, 5).

Much of the research on arthritis work disability has focused on rates of work disability, defined as complete work loss, and risk factors for it. A good deal less is known about what persons with arthritis do, (i.e., what work changes they make), in attempting to preserve employment. Awareness of what changes they make would provide a fuller understanding of the impact of arthritis on employment. More importantly, knowledge of the changes people make would facilitate evaluation of the outcomes of those changes to determine which are effective in preserving employment. Furthermore, an effective vocational rehabilitation intervention to prevent rheumatic disease work disability has been developed (6), and although it appears the need for such intervention is great, it is unclear what portion of employed persons with arthritis make effective changes on their own to preserve work and thus have little need for intervention.

Cutting down and back on employment activity may be a common way of dealing with the impact of arthritis on employment. In this issue of Arthritis Care & Research Gignac and colleagues examined cross sectional data about work changes made by 492 individuals with various types of arthritis (7). Six of the seven arthritis-related work changes they examined, loss of small amounts of work hours, use of sick days, use of vacation days, permanent reduction in work hours, inability to take on extra projects or responsibilities, and inability to seek promotions or job transfers, can be characterized as cutting down/back actions. The seventh work change, change in job, may or may not represent cutting down/back.

The results of the study by Gignac et al (7) showed that a majority (> 70%) of study participants had made at least 1 of the 7 changes, indicating these changes are common attempts to preserve employment. Evidence for use of some of these cutting down/back changes has been found in other arthritis studies, and for the most part, confirm fairly common use of these changes.

Greater use of sick days by persons with arthritis has been identified in several studies, e.g., a mean of 9.3 sick days in US citizens with joint disorders versus 4.9 days in the full sample (8). In a 1979 Canadian study, however, 50 employed adults with RA reported taking only an occasional sick day (9). A number of studies have data about reduction in work hours; all involved subjects with RA. Meenan et al reported that 14% of 180 subjects employed at disease onset had reduced their work hours (10), and Lucas et al reported that 31% of their sample of 88 subjects had either reduced work hours or changed jobs (11). Two other studies reported on subjects who had “adjusted” their work hours; an unreported number of subjects in Mancuso et al's pilot study of 22 employed women had done this (12), as had 21% of Chorus et al's study of 377 Dutch subjects (13). Adjustments included changes such as working four 10-hour days, as well as reduction in work hours. Unreported numbers of subjects in Robinson and Walter's 1979 Canadian sample (9) and in Mancuso et al's sample reported engaging in the work changes of inability to take on extra work or promotions.

There is slightly more information about change of job. In Robinson and Walters' 1971 study of 94 Canadian men employed at disease onset (14) about a third had changed jobs, primarily those in manual occupations. However, few of the 50 currently employed subjects in their 1979 study had done so (9). Yelin et al examined change of employer in 163 employed individuals and found that 35% had done so; of those staying with the same employer, an unreported portion had changed jobs with that employer (15). Changing jobs was a frequently cited adaptation in Mancuso et al's study (12), and 23% of Chorus et al's sample had changed jobs (13).

Employed persons with arthritis can make other types of changes to preserve employment as well. Changes mentioned by the 50 employed Canadian subjects were getting help with commuting, obtaining occasional help from others at work, timing duties according to fatigue level, and getting up earlier to manage morning stiffness (9). Subjects in Mancuso et al's study reported a greater variety of changes, e.g., working at home, using a car service, delegating more to others, and getting more rest (12). Chorus et al calculated the proportions of their sample that used selected changes; 57% had obtained additional job training after diagnosis, 42% used help from others, 20% used technical adjustments, and 16% adjusted job demands (13). Thirty-eight percent of Allaire et al's sample of 121 subjects with various rheumatic diseases used some type of job accommodation, the most common being special equipment, followed by rest periods, change in job duties, change in work hours, and change in work site accessibility (16).

Another approach to examining changes made to preserve work is to assess job accommodations provided by employers. Two studies assessing this have both used a list of 9 possible accommodations developed for the 1978 US Social Security Study of Disability. In a study of 469 persons with RA employed at disease onset, 53% of subjects had received at least 1 of the 9 accommodations (17). The second study used the subset of persons with musculoskeletal conditions and a disability from the US Health and Retirement Study and found that only 18% had received an accommodation (18).

Currently there is minimal information about the efficacy of various work changes. The results of 2 studies suggest that continuing employment with the same employer is effective. Most of the 50 employed Canadians had worked for the same employer for many years (9), and in Yelin et al's study, subjects who stayed with the same employer were more likely to remain employed than subjects who changed employers (89% versus 71%) (15). Other studies suggest that the nature of a job change has an important impact on effect. A significantly larger portion of currently employed subjects in Chorus et al's study had chosen their latest job with RA in mind than had subjects who were no longer working, suggesting some job changes are advantageous (13). Among employed persons with multiple sclerosis, the common career pattern of moving from a higher demand to a lower demand job led to complete work cessation (19).

The findings concerning reduction in work hours are mixed, but assessed differently in the 2 studies with relevant data. In their longitudinal study of RA work disability Reisine et al found that working less than 30 hours per week or using greater numbers of sick days predicted work loss (20). They speculated that reduction in work hours was indicative of a gradual withdrawal from the work force that culminated in premature departure. On the other hand, Chorus et al found that subjects who were currently employed were more likely to work less than 32 hours per week than had those no longer working (13). Employed subjects were also more likely to have adjusted their job demands, used technical adjustments, or obtained additional job training.

Evidence for the effectiveness of employer provided accommodations is also mixed. In Allaire et al's sample of persons with RA, work-disabled subjects had received job accommodations more often than employed subjects. Because the accommodations most commonly given, (i.e., provision of a helper, reduction in hours worked, and more breaks and rest time), would seem to lower productivity, they speculated that lowered productivity led to job loss (17). However, Yelin et al found that the one accommodation of provision of a helper was associated with employment retention in the Health and Retirement Study subset of persons with musculoskeletal conditions and disability (18). Moreover, in a study using the full Health and Retirement Study sample, provision of at least 1 of the 9 accommodations was associated with employment retention (21).

Gignac et al also assessed the psychological effect of the 7 work changes they assessed by examining level of depression in relation to number of changes made; subjects who had made more changes had higher levels of depression (7). Because the study was cross-sectional, the direction of the relationship cannot be determined. However, it is possible that cutting down and back work changes reduce ability to obtain satisfaction from work. In Mancuso et al's study, all but one of the women who changed jobs regretted the change. The effect of the changes was a cutback on careers, e.g., a successful trial lawyer changed to an entry-level position in a judge's office (12). Research has shown that the effects of chronic disease on employment reduce ability to obtain satisfaction from work and suggests that reduced job satisfaction leads to work loss (22). Mau et al found that low job satisfaction predicted low productivity in a RA sample (23).

The study of Gignac et al provides valuable information about some of the changes people make on their own to preserve employment. The results add to the body of literature on a topic for which there is relatively little information and provide unique information as well. The sample includes individuals with types of arthritis other than RA; therefore, it is easier to generalize the information. The study provides information about a broader range of cutting back/down actions, changes that are evidently commonly used. We now have up-to-date data about what portions of employed people with arthritis lose work hours, use sick days, and change to part-time work, in each case due to arthritis. We also now know that a sizeable percentage of people with arthritis use vacation days as “sick” days, as well as decline promotions and extra responsibilities. Another unique aspect and advantage of this study is that the psychological impact of changes made to preserve employment was examined. The fact that subjects who made more of the cutting down/back changes had greater depression suggests that alternative changes are needed.

As Gignac et al recognize, the main disadvantage of their study is that only cutting down/back changes were assessed (7). People with arthritis make other changes, (e.g., getting extra training and using special equipment), to preserve employment, and the limited evidence available suggests at least some of these other changes are effective in maintaining employment. It would have been useful to have more information about what portions of a general sample of persons with arthritis make these other changes and about the psychological effect of such changes. The tool used by Gignac et al to assess work changes was taken from a study on aging, which naturally (but not necessarily appropriately) focused on cutting back/down changes.

The findings in Gignac et al's study about the relationships among disclosure, individuals' perception of the effect of arthritis on work capacity, and expectations about remaining employed were complex and difficult to interpret (7). These relationships may become clearer as longitudinal data become available. However, the questions devised to assess disclosure and future employment expectation may not have measured what was intended. Instead of disclosure, the question asked whether a subject's employer knew of his/her arthritis, raising the possibility that awareness came about in another way. The authors stated they were interested in the effect of concern about ability to work in the future, but may have been overly restrictive in assessing this by asking if a subject anticipated leaving his/her job in the next year.

The fact that work disability is a major burden of arthritis is established, and risk factor studies have shown that work factors are important predictors of work disability. More recent research has shown that a job retention vocational rehabilitation intervention was effective in reducing rheumatic disease work disability (6). The intervention used professional assistance. We know relatively little about what work changes people and employers make to preserve employment without intervention, and very little about the outcomes of their changes. Data from the Gignac et al study suggest the approach often taken is to cut down and back on employment activities. Such actions may increase risk for work disability rather than reduce it. Gignac et al's article uses baseline data from a three-year longitudinal study (7). We look forward to learning more about the effect of the work changes they assessed on employment retention in future articles.


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