FfW Bulgarian report (English language) - Fit for Work Europe

Interventions
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medicalising’ their condition. The limitations imposed by sick notes, statutory sick leave and
formalised return to work programmes may serve to reinforce the ‘illness’ of the patient and
can tie employers hands. Based on evidence that psychosocial factors are a determinant
of chronicity and disability in those with back pain, there is a strong argument for reconceptualising
this condition and its treatment, which has important lessons for other types of
non-specific musculoskeletal pain (Burton, 2005).
Waddell and Burton (2006b) summarise the challenge neatly in their work on vocational
rehabilitation. They point out that, whilst many non-specific MSDs do not have clearly defined
clinical features and have a high prevalence among the working age population, most episodes
resolve themselves and most people with these conditions remain at work or return to work very
quickly. In their view, a focus on incapacity alone can be unhelpful:
‘..the question is not what makes some people develop long-term incapacity, but why
do some people with common health problems not recover as expected? It is
now widely accepted that biopsychosocial factors contribute to the development and
maintenance of chronic pain and disability. Crucially, they may also act as obstacles
to recovery and return to work. The logic of rehabilitation then shifts from dealing with
residual impairment to addressing the biopsychosocial obstacles that delay or
prevent expected recovery.’ (Waddell and Burton, 2006b, p.7) [bold in original text]
4.3.2 Rheumatoid arthritis
The importance of effective and early treatment of RA in reducing joint damage and disability is
now widely acknowledged (Pugner, Scott, Holmes and Hieke, 2000). Since there is currently no
‘cure’ for RA, the focus of treatment is on controlling signs and symptoms, enabling the patient
to manage their condition and improving quality of life. Medical treatments for RA are directed
at suppressing one or other part of the joint damaging processes, the effectiveness of which
has improved in recent years. Since it is well documented that the functional capabilities of RA
patients will decline over time, it is critical that patients should be treated as quickly as possible
with disease-modifying anti-rheumatic drugs (DMARDS) to control symptoms and disease
progression (Scottish Intercollegiate Guidelines Network (SIGN), 2000). One study found that
there is a 73 per cent risk of erosive damage in patients who wait over a year between symptom
onset and referral to rheumatology clinics (Irvine, 1999 in Luqmani, Hennell, Estrach, Birrell,
Bosworth et al., 2006).
Growing clinical evidence demonstrates that anti-TNF drug therapies can have a more powerful
effect on RA than DMARDs, especially in improving job retention and work participation
(Halpern, Cifaldi, and Kvien, 2008). However, figures show that the proportion of people with
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