Delivering NICE Joint Pain Advice in the workplace

Abstract Background Chronic joint pain is extremely prevalent, but its impact can be mitigated if people receive self‐management/lifestyle advice, especially about the importance of physical activity and maintaining a healthy weight. To reach the large number of people who needs support, we devised Joint Pain Advice (JPA), an intervention that can be delivered in a variety of health and community settings by a range of healthcare and non‐healthcare professionals. Here we extend JPA delivery into workplace settings. Method In each workplace, an advisor was trained to deliver JPA. This involved an initial assessment of participant's pain, musculoskeletal health and function (MSK‐HQ), number of days/week active for >30 min, and physical function. Participants were taught simple self‐management strategies, encouraged to adopt healthier lifestyles using motivational interviewing, goal‐settings and personalised action/coping plans. Participants were reviewed three times over 6 months, baseline outcomes reassessed, progress highlighted, health messages reinforced and action plans revised, if necessary. Results Twenty large public organisations or small/medium enterprises delivered JPA to 481 people. Satisfaction with the service was high; people found it acceptable, valued advice tailored to their individual needs and experienced tangible benefits—MSK‐HQ (9.5 points; CI 8.3 to 10.6), pain (−1.7; −2.2 to −1.7), physical function (−2.0; −2.2 to −1.7), activity levels and self‐confidence improved, whilst absenteeism and healthcare utilisation reduced. Conclusion Delivering advice about self‐management for chronic knee, hip and back pain in workplace settings using local health promotion or occupational health professionals and is practicable, beneficial and valued. JPA could benefit small, medium and large employers.


| INTRODUCTION
Worldwide back pain and chronic knee and hip pain (often labelled osteoarthritis [OA]) are leading causes of pain, disability, reduced mobility, physical and psychosocial health and well-being and quality of life (Hunter, Schofield, & Callander, 2014;Vos et al., 2020). In the United Kingdom, knee and hip OA affects 9 million people (Versus Arthritis, 2019), and about 10 million people have chronic low back pain (Li, Gignac, & Anis, 2006a;Versus Arthritis, 2019). These problems impact people's personal, social and working lives, impairing physical ability and mental well-being, causing anxiety, depression and reduced self-confidence (Versus Arthritis, 2019). They also have a wide socioeconomic impact through substantial health and social care expenditure and lost productivity (Li et al., 2006a). In the workplace, they can force people to change duties, reduce hours, and take sick leave and early retirement (Li et al., 2006a). Each year OA results in 3 million lost working days and back pain 4 million lost working days (Versus Arthritis, 2019) and one in four people who consult their GP about OA leave the workplace prematurely (Conaghan et al., 2015). As the prevalence of joint pain increases with age and the working age is extending, the impact of joint pain will increase (Business in the Community, 2017; National Institute for Health andClinical Excellence, 2009, 2014;NHS England, 2018;Public Health England, 2017).
International guidelines for the management of OA (National Institute for Health and Clinical Excellence, 2014) and back pain (National Institute for Health and Clinical Excellence, 2009) recommend providing people with information about the causes of their problems, along with reassurance, advice and self-management strategies, particularly emphasising the importance of physical activity and maintaining a healthy body weight, to improve all areas of people's lives. Chronic joint pain is usually managed by GPs, but employers are not legally required to allow employees time off work to see a GP. Moreover, GPs lack the time needed to enable people to adopt healthier lifestyles, such as supporting increase in physical activity and support weight loss (Basedow & Esterman, 2015;Cottrell, Roddy, Rathod, Porcheret, & Foster, 2016;Hurley, Walsh, Bhavnani, Britten, & Stevenson, 2010;Porcheret, Jordan, & Croft, 2007) or to provide the specific advice necessary to help someone remain in or return to work.
To reach the large number of people needing better advice, we designed a 'Joint Pain Advice (JPA)' service enabling a range of healthcare and non-healthcare professionals to deliver NICE advice.
In previous studies, people have found JPA easy to access, convenient, acceptable and effective in helping them become more active, and consequently have experienced less pain and better physical, mental and emotional well-being. They also report needing fewer medical consultations, investigations, medication and interventions (Hurley, Semple, Sibley, & Walker, 2019;Walker et al., 2017a) with an estimated social return on investment of 1:4 (Walker et al., 2017b).
Delivering JPA in workplaces could provide working populations with easier access to better care that increases their physical and mental health and well-being, enabling them to carry out their workrelated activities, reducing absenteeism (off work due to ill health [Demou et al., 2018]) and presenteeism (going to work despite illness [Skagen & Collins, 2016]) and creating a healthier, happier workforce.
This study evaluated the feasibility of setting up and delivering JPA services in small and medium enterprises (SMEs) and large public organisations.

| Design
A service evaluation delivered in workplaces to assess feasibility and effectiveness.

| Participants
To take part in the study: Employers had to be willing to allow existing employees time to be trained and to deliver JPA to employees, or allow peripatetic Advisors to deliver the service, and allow employees time off work to engage with the service; Employees had to have had knee and/or hip and/or back pain for at least 3 months, be over 40 years old experiencing knee or hip pain or over 18 years old if experiencing back pain, and be able to take time away from work to attend appointments; Advisors could be existing staff members who may be members of the occupational health department if the organisation was large enough to have one, or a peripatetic Advisor who travelled to several organisations.
Advisors had to undertake a half-day training course that taught them the ethos of JPA, its content, format and delivery, and how to measure the outcomes. The Advisors liaised with the employers and employees to book baseline assessments, deliver JPA and book the review appointments. They also contacted participants who cancelled or did not attend appointments to see why, re-book or determine reasons for withdrawal as appropriate, and collect feedback on the service.

| Intervention
JPA involved employees with chronic hip and/or knee and/or low back pain attending up to four 30-min face-to-face consultations, over 6 months with a trained Advisor (Hurley et al., 2019;Walker et al., 2017a; Table 1). The initial baseline consultation involved the Behavioural change techniques such as motivational interviewing, goal setting and action planning and pain coping and self-management strategies (rest-activity cycling, use of hot/cold packs, etc.) were used to nurture healthier lifestyles, in particular the importance of being active and maintaining a healthy body weight (Hurley et al., 2019;Walker et al., 2017a). An introduction to motivational interviewing was taught during the training; additional resources were provided and were encouraged to practice MI before starting appointments. Instead of providing 'answers and solutions', Advisors elicited from participants their experiences of living with joint pain, aims, ambitions, potential barriers, how these might be overcome and gave participants the major role in deciding what they wanted to do and how to achieve this. Subsequent review consultations approximately 3 weeks, 6-8 weeks and 6 months later repeated the outcome measures, reviewed progress, fed this back to the employee, reinforced the health messages and provided advice. They gave reassurance, motivation and encouragement to engage with local work or community activities and initiatives, such as walking groups, exercise classes or weight loss programmes where appropriate. This fostered a personalised, collaborative approach that enabled participants time to consider options and make changes alongside collaborative conversations.
The extent to which Advisors could address participant's concerns depended on the scope and boundaries of their existing role, skills and competency. Advisors highlighted accredited online resources and information (NHS, Public Health England, Versus Arthritis, Chartered Society of Physiotherapy, British Heart Foundation, etc), signposted participants to community services and, where necessary, participants were encouraged to speak with a GP, pharmacist, healthcare professional or social worker for health, psychological or social issues raised that were beyond their expertise.

| Outcomes
Descriptive data were collected of employee's age, gender, joint(s) affected, employment status and the sedentary/manual nature of their work. In addition, self-reported absenteeism and healthcare utilisation (medication usage, GP appointments) was taken at baseline for the 6 months prior to taking part in the JPA service and at 6 months for the 6 months of JPA. To evaluate the effectiveness of the JPA service, the quantitative outcomes collected at all appointments were; Musculoskeletal Health Questionnaire (MSK-HQ; Hill et al., 2016) which assesses people's physical, mental and emotional health and well-being, ability to work and quality of life related to musculoskeletal problems; pain experienced over the previous 2 weeks on a Numerical Rating Scale of 0-10, where 0 = no pain and 10 = the worst pain they have ever had; Physical ability the number of sit-to-stands a participants could perform from a chair without using their arms in 30 s (Jones, Rikli, & Beam, 1999); Physical activity was determined by the number of days per week participants reported they undertook ≥30 min of T A B L E 1 Outline of the Joint Pain Advice service

Reinforcement of health messages and advice
Provision of on-going support, reassurance, motivation and encouragement Participants encouraged to take up activities through sign-posting if they have not already done so 6-month review As above HURLEY ET AL. moderate intensity physical activity; their confidence in their ability to self-manage their problems. These outcomes were also shared with each employee to feedback progress, reinforce health messages and motivate participants.
Satisfaction with the JPA service was determined by inviting all participants to complete an anonymous online satisfaction questionnaire, and the NHS Friends and Family Test where participants were asked if they were 'very likely/likely/neither likely nor unlikely/ unlikely/very unlikely' to recommend the JPA service to family and friends.
Referral rates, uptake, 'failure to attend' and adverse events were recorded to determine feasibility and acceptability of the service.

| Data analysis
To evaluate the effectiveness of the JPA service, the clinical outcomes were summarised using descriptive statistics, and paired two sample t-tests used to compare the means between baseline and review assessments. For healthcare utilisation, self-reported usage in the 6 months prior to baseline assessment was compared to the healthcare utilisation between baseline and the 6 months assessment. Statistical significance was set at p < 0.05. Statistical analysis was conducted in Rstudio (Version 1.1.383; Rstudio Inc.).
Satisfaction with and acceptability of the JPA service was assessed from the percentage responses to the satisfaction questionnaire, attendance and retention of employees on the JPA service.

| Retention
Overall, JPA attendance and completion rates were moderate, withdrawal usually occurred after the first appointment, retention at 3 weeks was 79%, at 6 weeks 675 and at 6 months 53% (Table 3).
Reasons for attrition included joint pain improved/resolved, ineligibility, unable/unwilling to commit time due to work or personal commitments, expecting 'a quick fix', expecting a clinical intervention, other health issues, inconvenient appointment times and employers not releasing employees to attend appointments.

| Benefits
Following JPA, there were significant improvements in employee's MSK health (MSK-HQ), pain, function, disability and physical activity (Table 4). -559 adjustments to their workplace environment and practices, and 62%

T A B L E 2 Characteristics of participants
reported changing the way they did things at work.

| Healthcare utilisation
In the 6 months prior to JPA, the majority of participants (291 of 399, 73%) had accessed some form of healthcare-a consultation, investigation and/or intervention ( Figure 1) and most (81%) were taking medication for their knee, hip and/or back pain. In the 6 months after initiation of JPA, the majority of participants had no investigations (73%), fewer people had consulted about or had interventions for joint pain (Figure 1; Table 4) and the number of participants taking medication, the number of medications taken and frequency of medication (i.e., taken daily, weekly, monthly or rarely) decreased.
Fewer workdays were lost in the 6 months following initiation of JPA compared to the previous 6 months (Table 4).

| Costs
Delivering JPA involved salary of Advisors for 4 � 30 min appoint-  lose weight and take exercise this is rarely sufficient to effect behavioural change and get them to adopt healthier lifestyles (Walsh & Hurley, 2005). Physiotherapy aims to reduce pain and improve function, but not sustained behavioural change, self-management or self-reliance, so subsequent courses of physiotherapy, GP visits, investigations and interventions are usually necessary. However, accessing these healthcare services is difficult, and following the recent COVID-19 pandemic likely to be more so. JPA not only improves access to better care it also signposts participants to services offered in their workplace or communities (e.g., exercise, weight management, smoking cessation) to help them adopt healthier lifestyles, which would produce a healthier, happier work force, reducing absenteeism, presenteeism and maximising productivity.

| Strengths and limitations
The main strength of this study is its pragmatic design. Our study is a what happened to all of those participants. Participants who Advisors contacted after they failed to attend an appointment often said they felt they had received enough advice in the initial appointments to enable them to self-manage their pain better themselves, so they no longer needed the service. This is corroborated by the high satisfaction with the JPA service, and matches high withdrawal despite high satisfaction we found in previous studies (Hurley et al., 2019;Walker et al., 2017a). We contend that high withdrawal does not reflect the failure of an ineffective or unneeded service, but rather people self-managing their problem by choosing what help they needed, when they needed it and which was the prime aim of the JPA service. Creating flexible, accessible, efficient services that can be accessed when needed (Davison, 2000;Maddison et al., 2004;Smink et al., 2011;von Korff & Moore, 2001;Walker et al., 2018) maximises the efficiency of JPA by targeting care to people who need it, when they need it.
Finally, some of the costs of JPA cannot be easily incorporated in the estimated costs of the service [£62; €70; $83]; these include planning, initial and on-going implementation of the service and loss in productivity incurred releasing employees to attend appointments.
Some of these will be one-off costs that will be offset over time, and staff time is likely to be recouped through reduced absenteeism and presenteeism. Furthermore, the estimated cost only reflects the cost of the 'in house' model; the costs of the 'peripatetic' model is harder to estimate as it depends on who is delivering the service, and how it is set up. In addition, healthcare utilization, presenteeism and absenteeism were self-reported, and we did not have the resources to corroborate.
However, self-report has been shown to be reasonably accurate (Beckett, Weinstein, Goldman, & Yu-Hsuan, 2000) in relatively young people, for a slowly progressive condition such as joint pain, that entails few investigations, interventions and medication.
In summary, in spite of chronic joint pain being very common and a There are now many types of 'champions', such as health and safety, fire and mental health champions, who are trained to make workplaces safer, healthier environments. People trained to advise and look after the large and growing number of people with chronic knee, hip and/or back pain in the workplace could bring significant returns for relatively little outlay.