Bone and Joint Decade 2010-2020

Global Alliance for Musculoskeletal Health

World Summit

London, 13 October 2014

Dame Carol Black

Expert Adviser on Health and WorkDepartment of Health and Public Health England

Principal, Newnham College Cambridge

The Importance of Musculoskeletal Health

in the Workplace

Theme of the talk

• The burden of MSD is very large, affecting both YLDs (years lived with disability) and DALYs (disability-adjusted life years).

• MSDs prevent people from working or working well (presenteeism – leading to poor productivity and job loss)

• MSDs may be a ‘proxy’ for bad work or workplaces

• MSDs cause worklessness which affects length and quality of life

• Close association of MSD with mild mental disorders, and of some MSDs with obesity – a further burden.

• A healthy workforce is needed to fuel a healthy economy. It also provides income from taxation to fund public services.

What prevents us from working – or from working well ?

• Common mental health problems

• Musculo-skeletal problems

• The quality of work and the workplace - organisation of work- managerial behaviour and leadership- absence of ‘good work’

• Other important reasons- long-term conditions – mental and physical- psychosocial/ home-related problems- lack of education and/or skills.

Musculoskeletal Disorders in the EU Workforce

Unemployment rates are three times higheramong people with MSDs than in the general population.

MSDs: The burden in Europe

UKAt least 33% of the adult population suffer significant back pain at some stage. Cost of MSDs estimated at £7bn per year.

Belgium (for example): Direct and indirect costs of absence rose from €8.2 bn in 2006 to €10.35 bn in 2008: of absence, 40% is attributable to musculoskeletal problems

The Fit for Work Europe coalition conducts applied research on prevalence and impact of MSDs in the working-age population of 35 countries in Europe and beyond. Goals:

• influence governments• show impact of MSDs on productivity and business• promote early intervention.

Source: OECD (2014), Mental Health and Work: United Kingdom, Paris: OECD Publishing. Courtesy Shruti Singh

New UK disability claims are among the highest in the OECDNew claims per 1,000 of the working-age population (inflow rates), latest year available

0

2

4

6

8

10

12

OECD

average

UK: Disability burden and the benefit system

Earlier intervention could improve this

The crucial interfaces

The interface between patient/employee, health professionals and employer needs to satisfy all parties.

Essential ingredients: • well-informed, work-knowledgeable

health professionals• employers that create good work

and good workplaces• employees engaged, with good wellbeing.

14

12

10

8

6

4

2

0

RA (mean)General Pop. (mean)

-12 -11 -10 -9 -8 -7 -6 5 -4 -3 -2 -1 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12

Months after RA diagnosis

Day

s of

sic

k-le

ave

and

disa

bilit

y pe

nsio

npe

r mon

th

Patients diagnosed 1999-2007; n=3029. General population comparators matched 5:1 on age (±1 year), sex, education level and country. RA, rheumatoid arthritis.

Neovius M, et al. Ann Rheum Dis 2011;70:1010-15.

Days on sick-leave and disability pension before and after diagnosis

• Late diagnosis?

• Treatment ?

• Employer response?

• Patients’ response to disease?

Example : Rheumatoid Arthritis – Impact on Work

Job loss and benefit claims with early RA

D.F. McWilliams et al, Rheumatology, 2014;53:473-481

• Study aimed to identify predictive factors for work disability and state benefit claims in cohort with early RA

(Early RA Network, ERAN: 22 centres in UK and Ireland)

• 1,235 participants annually reported employment status & benefit claims.

• At baseline, 47% were employed and 17% on benefits due to RA.

• Within 3 years, 10% of the employed lost their job due to RA, and 20% of those not initially claiming benefits were doing so.

• Work disability was predicted by pain and low vitality

• New benefits claims were predicted by baseline disability, extra-articular disease manifestations, and disease activity.

RA & Work

1 in 5 give up work within 5 

years

RA can reduce productivity by 40 days pa.

Almost 1 in 5 report poor support at 

work as a barrier to job retention

Most patients are in careers when RA is diagnosed

Popular ‘mythology’ about RA persists

Workers with RA are 3‐5 times more likely to stay in work with changes to 

job demandsRelationship 

between RA and depression poorly 

understood

Rheumatoid Arthritis and Work

Courtesy S Bevan The Work Foundation

What is needed

• Good clinical care, early diagnosis, early intervention, “work-conscious” Vocational Rehabilitation.

• Employer support, flexible working, workplace adaptation (in UK using the Government’s scheme Access to Work)

• Fully-informed patients, co-creating health.

Note : in UK about 25% of people with arthritis report a co-morbid mental health condition.

Around 19% of those absent from work due to chronic pain are depressed (but only 8% of all workers).

If MSDs are managed effectively, disability can be minimised and disease progress stopped or delayed – thus extending working life.

Spain : Early Intervention to reduce Musculo-skeletal Work Disability

• Hypothesis : An intervention programme, integrated into the health system and offered to the working population ; could it reduce the impact of MSD-related temporary work disability ?

• A randomized controlled study over 12 months evaluated the cost-effectiveness of a population-based clinical program offered to patients with recent-onset work disability.

• The study included all patients with MSD-related temporary work disability in 1998 and 1999 in three health districts in Madrid.

Abasolo L et al, Ann. Intern. Med. 2005;143;404-414

Spain : Early Intervention to reduce Musculo-skeletal Work Disability

Control Group 7,803, Intervention Group 5,272 patients : 16,297 episodes.

• Controls received standard management, specialist referral if needed.

• Intervention group received in a Rheumatology Department a specific programme with :

(1) education; (2) protocol-based clinical management; and (3) other input usual in primary care

(e.g. prescriptions, certification, reports etc).

• Efficacy measurements: (1) days of temporary work disability; and (2) number of patients with permanent work disability.

(Analyses done on intention-to-treat basis.)

Spain:Early Intervention for MSDs

14

Results: (The groups had similar numbers of episodes per patient. Most patients returned to work within 2 months: after 6 months few returned.)

Duration of temporary disability reduced by 46% Incidence of permanent disability reduced by 40% Utilization of health care resources reduced by 40% Analysis showed that 1 euro invested in the

early intervention programme yielded 9 euros of benefit

If replicated across the EU this intervention would allow 1m additional workers to attend work each day

Employer targeting the same problem : Severn Trent Water

STW had a growing number of employees off sick long-term, or on long-term restricted duties affecting productivity and performance.

Many had MSDs but there was poor access to timely effective physiotherapy.

The company developed a work-focused approach to physiotherapy, and introduced a functional rehabilitation programme delivered by experts.

Achievements of new service: • 15% reduction in musculo-skeletal absence• of 22 who took the functional rehabilitation

programme, 19 returned to work full time• employee engagement scores

now a positive 81%.

CBI Getting Better

Determinants of Employment

• “Employment is not determined solely by the measurable pathological effects of the disease, but also by the influence of the job and various psycho-social factors.

Dissatisfaction with working conditions can often be counteracted by escape to outside interests, which unfortunately include ill-health and absence. ” (Chiesman)

• “ Much musculo-skeletal disability attributed to occupational injury is the consequence, not of disease, but of a psychologically-mediated response to an external trigger, conditioned by individual characteristics and cultural values, beliefs and expectations.” (David Coggon)

• Various psychological/social and mechanical work factors predicted back pain severity in a longitudinal study.

(Christensen et al)

1957

2011

2012

Musculoskeletal Problems : What and Why

• Back pain, neck pain, soft-tissue problems- high prevalence across populations- little or no objective disease or impairment- most episodes settle rapidly, though symptoms

often persist or recur- essentially whole people, should be manageable.

• These symptoms are often an expression of, or reaction to, poor work, poor workplaces, and/or poor leaders or managers.

• Health interventions such as drugs, ergonomics, physiotherapy etc can help

BUT may not fully address the real root problem(s).

Musculoskeletal Health –the Less Obvious

Good work Good workplaces• Stable and safe• Individual control• Fair work demands

• Flexible arrangements• Opportunities – training,

promotion• Promotes Health and WellBeing

• Prevents isolation, discrimination • Shares information• Reintegrates sick /disabled if

possible

• Visible senior leadership• Accountable managers

throughout • Monitoring and measurement

to ensure improvement• Attention to both mental and

physical health • Empowering employees to care

for their own health• Fairness to all • Flexible working

MSDs relate and interact with :

Predictors of back painare not always ‘medical’

After adjustment for age, sex, skill level, back pain severity and other potential confounders, the most consistent predictors of back pain were:

• decision control at work(lowest OR 0.68;

99% confidence interval (CI): 0.49 -0.95),

• empowering leadership at work(lowest OR 0.59; 99% CI: 0.38-0.91)

• fair leadership at work(lowest OR 0.54; 99% CI: 0.34-0.87) Christensen JO, Knardahl S. 2012

Do not forget the psycho-social …

Important Factors and Relationships

Interact and affect ability to work

Obesity

MSK problems

Mental Health

Example: MSDs and mental health in Australia

• People with MSDs are 1.5 times more likely to report mental disorders

• Affective disorders are 2.5 times as likely in those with back problems

(National Survey of Mental Health and Wellbeing, 2007)

• International Occupational Health research has consistently shown the importance of adverse socio-organisational factors at work as determinantsof work-related MSDs, as well as physical factors, yet these are neglected in OHS standard setting by WHS authorities in Australia

(Ellis, N, The Conversation, 31 July 2012)

Work, health and society

Society needs the maximum number of productive years from as many people as possible. Those not working depend on others.

The ratio of earners and wealth-generators to dependants (children, pensioners, unemployed) needs to be as high as possible.

Childhood Working life Retirement

Musculo-Skeletal Diseases are the second greatest cause (globally) of Years lived with Disability, and (in the UK) of sickness absence.

Challenge: minimise disability and mitigate its effects on function, enabling participation in work and extended working life.

Being sufficiently healthy is a condition for work, and maximising disability-free life as a proportion of total life is therefore a desirable goal for individuals, health professionals and society.