Inflammatory arthritis (IA), also called rheumatism, is a group of diseases that cause long-lasting pain, stiffness and swelling in the joints. These symptoms make it difficult to move and make you feel tired, which in turn can make it difficult to work. The most common types of IA are: rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Worldwide about 3% of people have IA. The disease usually begins when people are between 30 to 40 years old, at a time when they still have many years of working life left. Therefore, it is important to know if there are effective ways in which we can help people with IA stay at work. This Cochrane Review focuses on non-drug interventions.
Trials we found
We searched the available literature up to 30 April 2014. We included three randomised controlled trials with 414 participants who had IA and who were at risk of losing their jobs. These trials first evaluated how the work environment could be adapted and then provided counselling, advice or education for work problems. One trial gave two 1.5-hour sessions over five months. Another trial gave two consultation and multidisciplinary treatments during three months. The third trial gave six to eight individual or group sessions over six months. The included trials compared the effects of interventions to usual care (two trials) or to written information only (one trial). Two of the included trials measured the effect of the intervention on job loss (382 participants) when the third measured effect on work absenteeism and work functioning (32 participants).
What the research says
When considered together, the evidence from the three trials was of very low quality. Two trials found different results on job loss measured at two years' follow-up: one trial on job counselling found a large reduction in people who lost their job and the other trial found similar effects in both groups. Another trial did not find a considerable effect on absenteeism at six months' follow-up but found a moderate improvement in work functioning.
Because of positive results from one RCT with long term follow-up, we see potential for job loss prevention interventions in helping workers with inflammatory arthritis to stay at work. The certainty of these results is limited by the very low quality evidence of the three RCTs overall.
This Cochrane review of three RCTs found very low quality evidence overall for job loss prevention interventions having an effect on job loss, work absenteeism and work functioning in workers with inflammatory arthritis. While this review highlights that further high quality RCTs are required, the results suggest that these strategies have potential to be effective.
Work participation of patients with inflammatory arthritis (IA) is important not only economically but also for physical and psychological health. There is no Cochrane Review to date on studies of non-pharmacological interventions specifically aimed at preventing job loss in people with IA.
To assess the effects of non-pharmacological interventions that aim to prevent job loss, work absenteeism or improve work functioning for employees with IA (rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), other spondylarthritis (SpA) or IA associated with connective tissue diseases, such as Systemic Lupus Erythematosus (SLE)).
We searched the following databases from inception up to 30 April 2014; The Cochrane Library (including Cochrane Central Register of Controlled Trials, i.e. CENTRAL and DARE), MEDLINE (PubMed), EMBASE (Embase.com), CINAHL (EbSCOhost), ClinicalTrials.gov and PsycINFO (ProQuest). We did not impose language restrictions in the search.
We included randomised controlled trials (RCTs) that evaluated interventions aimed at preventing job loss in adults of working age (18 to 65 years) diagnosed with IA, including RA, AS, PsA, SpA or other types of IA. Primary outcomes were job loss and sickness absenteeism and the secondary outcome was work functioning.
Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias in the included RCTs.
We included three RCTs with a total of 414 participants at risk of job loss. The majority of participants had IA, most with RA and to a lesser degree AS. The interventions aimed to prevent job loss and improve work functioning in several ways: firstly by evaluating work changes or adaptations and secondly by providing any person-directed interventions including vocational counselling, advice or education. Interventions directly targeted at the work environment were minimal and included workplace visits (one trial) or any actions by an occupational physician (one trial). The duration or dose of the interventions varied from two 1.5-hour sessions (one RCT) over five months, two consultation and multidisciplinary treatments during three months (one RCT), to six to eight individual or group sessions over six months (also one RCT). All participants were recruited through rheumatology clinics, both in or outside hospitals. Included trials investigated job loss (n = two RCTs; 382 participants), work absenteeism and work functioning (n = one RCT; 32 participants). Overall, we evaluated the two smaller trials as having a high risk of bias and the large trial as having a low risk of bias. Trials showed marked differences in how they performed on risk of bias items, particularly on performance bias.
We assessed the quality of the evidence using the GRADE approach and judged there to be very low quality evidence across the three reported outcomes. Of the two RCTs investigating job loss, the larger one (n = 242 participants) reported a large statistically significant reduction in job loss (relative risk (RR) = 0.35, 95% confidence interval (CI) 0.18 to 0.68) and the other RCT (n = 140) reported similar effects in both groups, although the CI was very wide (RR = 1.05, 95% CI 0.53 to 2.06). The latter one probably suffered from performance bias and we judged it to have a high risk of bias. The one small trial investigating sickness absenteeism found uncertain results at six months' follow-up (MD = -2.42 days, 95% CI -5.03 to 0.19). Finally, in the same small trial investigating work functioning using the Rheumatoid Arthritis-Work Instability Scale (RA-WIS), there was a moderate improvement of intermediate term work functioning (six months; scale range 0 to 23; mean improvement -4.67 points, 95% CI -8.43 to -0.91). We identified no adverse effects in the publications of the three trials.