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Factors influencing return to work after hip and knee replacement: a
systematic review of qualitative and quantitative literature
Abstract
Background: Return to employment is one of the key goals of joint replacement
surgery in the working-age population. There is limited quantitative and qualitative
research focusing on return to work after hip and knee replacement. It remains
unclear why certain groups of patients are not able to achieve sufficient functional
improvement to allow productive return to work whilst others can. Very little is known
about the individual patient and employer perspectives in this regard. Current
evidence for the factors influencing employment outcomes in patients undergoing hip
and knee replacement is the subject of this review.
Methods: Original articles and reviews in Medline, Embase and Psychoinfo from
1987 to 2013 were included in the analysis.
Results: Age, patient motivation, employment before surgery and type of job are
important factors in determining return to work following hip and knee replacement.
Conclusion: There is a need for further qualitative work on how and why these
factors influence employment outcomes.
Key words: arthritis, occupational rehabilitation, qualitative
Introduction
Hip and knee arthritis causes significant problems in the working-age population and
can lead to a reduced quality of life, change in employment or unemployment. The
10th National Joint Registry reports that 18-20% of patients undergoing hip and knee
replacement in England and Wales are under the age of 60 years. Joint replacement
may enable patients to continue working, which may be more cost-effective in the
long term as patients remain economically productive members of the society.
Heavy lifting and bending have been reported as important factors in the
development and progression of arthritis. The effect of arthritis on employment
depends on the type of work usually performed, with manual or lifting jobs
associated with increased levels of unemployment due to arthritis. In addition to a
loss of employment, arthritis has also been associated with a prolonged sickness
absence or a change in the type of work performed. In patients with rheumatoid
arthritis, the common factors that influence work disability include employment
factors (nature of job, physical activity, degree of autonomy at work, work
environment and transport to work), employee factors (age of onset of disease,
education, motivation and marital status), disease factors (time since onset, level of
disability and flare ups), and other factors, such as time taken for healthcare, in-
patient care, and/or rehabilitation.
Previous studies have quantitatively assessed the role of surgery in returning the
patient to work after joint replacement . In a systematic review, Kuijer et al concluded
that the literature was sparse regarding factors affecting return to work after knee or
hip replacement. While quantitative studies can identify the extent to which surgery
helps in return to work, these methodologies do not examine the perspectives of
patient or employer which would be better determined by qualitative studies.
Qualitative research aims to develop theory on individual decision making or
behaviour by gathering in-depth interview data prioritising the views of a small
number of patients or groups. In addition, qualitative approaches can develop
understanding of the experience of arthritis and its treatment, and highlight the
particular significance it may have for different categories of patient at different
stages of treatment. Since there is an emergent body of qualitative literature on
arthritis and joint replacement, this article aims to review this literature to establish
whether and how qualitative research has informed findings from the quantitative
literature on joint replacement and return to work among those of working age.
This review of qualitative and quantitative literature aims to address the following
questions:
1. What are the employed patient’s expectations from a joint replacement before
and after surgery?
2. Who is most at risk of not returning to work after joint replacement surgery?
3. What external factors are important to help patients return to work?
4. Does age of the patient determine their ability/motivation to return to work?
5. Are patients able to return to work at the same level?
Methods
A systematic literature review was conducted of the databases Medline, Embase and
PsychInfo for peer reviewed articles on humans using the search terms ‘qualitative’
and each of ‘joint replacement’ (66 citations returned), ‘knee replacement’ (90
citations returned) and ‘hip replacement’ (68 citations returned), limited to papers
from 1987 to 2013. Papers were excluded if they concerned: operations other than
hip or knee replacement; living with osteoarthritis (OA) without consideration of total
joint replacement (TJR); experience in primary care only; or questionnaire
development. Study protocols for randomised controlled trials (RCTs), quantitative or
biological studies using the word ‘qualitative’ were excluded. 47 articles were
identified, of which 3 were review articles. A second literature search was carried out
for quantitative research using keywords ‘employ$’ or ‘work’ AND each of ‘joint
replacement’, ‘knee replacement’ and ‘hip replacement’, limited to papers from 1987
to 2013. Further papers from reference lists of the remaining articles were also
followed up.
Results
Summary of qualitative literature (Table 1)
Expectations and patient decision processes prior to hip and knee replacement
There is an emerging body of qualitative studies of OA patients’ experiences and
views on TJR prior to surgery, in particular considering how these may impact on the
decision whether or not to undergo surgery. A meta-synthesis of qualitative research
exploring reasons for unmet need for total knee replacement (TKR) identified 10
studies, including four from the UK; the majority included the views of patients
awaiting either hip or knee replacement. Most studies conducted in-depth or semi-
structured interviews with samples of 17-27, though Figaro et al had a sample of 94.
Various analytic approaches are adopted: thematic, grounded theory, framework,
phenomenological or content. Participants’ ages typically ranged from early 50s to
early 80s, although Woolhead et al included participants as young as 40. Where
mean ages of participants were given, these ranged from 64-76, suggesting that
those of working age are not broadly represented in this research.
These studies highlight the complexity of the decision-making process for patients,
with socio-cultural categories of aging and the role of the health care professional
being central to forming patient’s expectations around surgery. A fluid risk/benefit
threshold and culturally specific factors are likely to argue against deciding upon
surgery. The meta-synthesis concluded that coping strategies and life context were
likely to be influential on outcomes of the operation; one study found that the
indeterminacy, pain and disability experienced while on waiting lists resulted in a
sense of disenfranchisement, and a sense of lack of presence in one’s own life.
These factors also boost hopes among patients for the potential of the joint
replacement operation to transform their situation. In this context, Woolhead et al
found that waiting patients’ expectations for the impact of surgery were not clearly
formed. They could express ideal or pragmatic hopes, but indicated that they did not
understand procedures clearly enough to say whether they expected a particular
outcome. This literature was also reviewed in 2009 to illustrate the potential of
qualitative approaches.
Since O’Neill et al’s meta-synthesis a number of studies have explored this area
further with broadly similar theoretical approaches and samples. For instance, one
Swedish study interviewing 10 patients (mean age 65) awaiting hip replacement
found their outlook characterised by endurance or resignation in the face of impaired
mobility and great pain in their daily routine. Some studies have employed focus
group interviews rather than individual interviews. Patient interviews have also been
complemented with clinician interviews and observations. Findings, however, are in
general consistent with the earlier studies, with perhaps more consideration of, or
emphasis on, the specific education needs of patients awaiting or considering TJR.
Two studies note that some patients interviewed individually or in focus groups
identified barriers to employment (difficulty walking to sites and with sitting or
standing in offices for long periods) as part of the ‘final straw’ prompting their choice
to undergo total hip replacement (THR). Heaton et al note that in making this choice,
patients may have developed heightened expectations of the likely impact of THR on
their ability to work. In general, however, this literature offers no specific comment
on working lives of individuals awaiting joint replacement.
Expectations before compared with experience after hip and knee replacement
There have been fewer qualitative investigations of patient perspectives following
TJR. Although O’Neill et al’s meta-synthesis focused on the preoperative decision
process, three of the included studies also gathered data on patients’ views in the
wake of surgery. One study reported on a focus group of five patients who had
received hip or knee arthroplasty. The authors identified difficulties applying learned
skills and coping with pain in the post-operative period, and concluded that better
education before surgery on best and worst outcomes could reduce distress arising
from a mismatch between patient expectations and experience. A grounded theory
study from New Zealand of nine patients interviewed about pre- and post-operative
experience recommends support to help patients maintain their optimism throughout
the perioperative period. Woolhead et al also followed up post-operatively ten of the
patients they had interviewed prior to TJR surgery. They found that those patients
moved in their interviews from an initial assertion that their operation had left them
with few symptoms or none, to stating that they still suffered pain and disability. It
was found that they struggled to make sense of their experience and outcomes,
some blaming themselves for pain or disability for instance because they had been
‘overdoing it’. These findings are also summarised by Dieppe et al.
A meta-synthesis of 16 studies of older patients being discharged from hospital
following either hip or knee replacement identified common constructs across studies
of loss of independence, functional and activity limitations and coping with pain, all of
which bore a crucial relationship to mental outlook. Content analysis of short
interviews with 30 UK inpatients in the six weeks following a knee replacement
operation identified concerns at this stage with a wide range of aspects of life. In
France a substantial qualitative dataset, covering all stages of OA and treatments,
was gathered through interviews with 81 primary care patients with OA and 29
consultants. Patients receiving knee replacement indicated dissatisfaction with
outcomes of the surgery, and reported they were still suffering more pain than they
had expected in follow-up interviews. Patients interviewed in Sweden have also
emphasised their experience of overwhelming pain while in hospital following hip
replacement.
However, in a UK study following up hip replacement patients aged 44-83 at one to
two years, patients said they had learned to emphasise positive outcomes and
alleviate the harmful effects of pain and physical limitations by reinterpreting the
meaning of their lives allowing them to cope with their post-operative pain and
discomfort. In Sweden Gustafsson et al interviewed joint replacement patients aged
65 or above, longitudinally, in five sequential interviews over the two-year period
from joining the waiting list to cessation of post-operative care. Their analysis
highlights the ‘dream’ of becoming able-bodied and escaping bodily confinement and
pain as central to patients throughout the process, but they found that patients’ lack
of knowledge about surgical procedure had not prepared them for the transitional
changes (rethinking their beliefs and perception regarding their bodies) that were
required following their surgery. Other interview and focus group studies in the UK
and USA have also found that unrealistic expectations in patients led to them feeling
frustrated, less confident and independent than they had anticipated, and less able
to participate in activities in the months following surgery. Heaton et al note that the
nine of their 52 interviewees who described dissatisfaction with their hip replacement
after four months had suffered complications or problems with their operations, and
were frustrated that the slow rate of their recovery was preventing them returning to
work.
The importance of supportive care from health care professionals throughout the
perioperative period in order to facilitate joint replacement patients’ transition is
stressed by all authors. Four studies have noted that the accounts of their release
from hospital suggest paternalistic relationships with, or orientation towards, health
care providers, although studies interviewing patients in Finland and Sweden
following hip arthroplasty find strong post-operative satisfaction with health care
providers. Family support may be crucial to successful rehabilitation following
release from hospital. In Canada, the increasing numbers of TJRs performed and the
changing profile of those receiving the operations towards younger age groups have
increased the need for rehabilitation services. A study from New Zealand concluded
that prehabilitation, postoperative nursing care and discharge planning can help in
patients’ optimism and motivation to self-help and patient teaching should reflect
realistic recovery process.
Summary of quantitative research on employment outcome after hip and knee
replacement (Table 1)
Our search did not reveal any qualitative study looking at employment outcome after
total hip and knee replacement. Quantitative analyses have however been
performed.
Who is most at risk of not returning to work after joint replacement surgery?
Lyall et al, in a study on employment outcome after total knee replacement showed
that 40 out of 41 patients (97.5%) who were working pre-operatively went back to
work within six months.. Patients were often back at work in six weeks and 35
patients (85%) were pleased with the result of the operation. In their study,
individuals not working pre-operatively did not resume working postoperatively. The
mean period of unemployment in their group before operation was 35 months
(range, 21–58 months). Their results show 80% of patients in the unemployed group
prior to total knee replacement had previously performed manual jobs, involving
prolonged periods of standing, lifting and bending down and 20% were performing
non-manual jobs. Overall, eight patients (53%) were pleased with the results of the
operation. This study indicates that patients working pre-operatively are highly likely
to continue working after total knee replacement. However, total knee replacement is
unlikely to facilitate return to work for the already unemployed.
Jorn et al concluded that the patients who were on sick leave for less than 180 days
preoperatively had better health profile (Nottingham Health Profile – in terms of
emotion, energy, pain, physical mobility, sleep and social isolation) than those who
were off for more than 180 days and were more likely to return to work
postoperatively.
Mobasheri et al examined the effect of total hip replacement on employment status
in patients under 60 years of age. They found 49 out of 51 patients returned to work
after total hip replacement if they had been working pre-operatively, a return to work
rate of 96%. Half of patients off work pre-operatively returned to work after hip
replacement. They concluded if a patient was off work due to hip pain then total hip
replacement would facilitate a return to work. However, Mobasheri et al also reported
a reduced rate of re-employment in patients who had been unemployed for more
than one year before operation. Malek et al noted that at ten years after hip
resurfacing 90% of patients were in the same employment after surgery, with no or
minimal restriction.
What external factors are important to help patients return to work?
Kuijer et al in their systematic review, where they only found three studies suitable to
be included, reported that surgical approach and type of operation may have an
influence on return to work; restrictions on patient movements have a negative
influence; discharge guidelines have no effect and the percentage of patients
returning to work and time to return to work varies. The timing of discharge from
hospital does not influence the number returning to work. This review clearly
highlights the limitations of available literature to draw relevant and meaningful
conclusions and the need to perform more robust studies.
Styron et al explored the preoperative predictors of returning to work after primary
total knee replacement and concluded that although the physical demands of a
patient's job have a moderate influence on the patient's ability to return to work
following a primary total knee arthroplasty, the patient's characteristics, particularly
motivation, play a more important role. They concluded that the median time to
return to work after knee replacement was 8.9 weeks, with patients who had a sense
of urgency to return to work taking half the time of the other group.
Foote et al found that the type of procedure may influence employability, with
patients undergoing total knee replacement and unicondylar knee replacements
having better return to employment as compared with patellofemoral replacement,
while the physical intensity of the work remained the same.
Does age of the patient determine their ability/motivation to return to work?
Bohm et al in a review of 60 patients who had undergone total hip replacement
concluded that the patients who returned to work were younger (mean age 49.9
years versus 60.3 years), less likely to be collecting disability insurance, had better
physical function and Oxford-12 hip score, less functional limitation from medical
conditions and conversely, poorer job satisfaction before surgery. They did not find
any difference in the groups in terms of physical demands at job or workforce
flexibility. Patients reported an increase in income, decrease in number of hours per
week of work, increased productivity and increased ability to cope with physical
demands of workplace. They concluded that surgery should be undertaken before
the patient’s hip dysfunction forces them off work.
Are patients able to return to work at the same level?
Mariconda et al found that 82% of patients after total hip replacement were able to
return to the same physical demands after surgery while about 14% had to take a
more sedentary role.
Styron et al reported that patients with less pain preoperatively, more physically
demanding job and receiving workman’s compensation (sickness benefit) returned to
work slower. Jorn et al concluded that patients with a light workload preoperatively
returned to work sooner.
Discussion
Patient views and experience leading up to surgery are quite well covered in the
literature. with relative similarity of findings and conclusions in studies from different
countries using varied methods. However, there is scope for considerably more work
exploring patients experience after surgery, with only a handful of studies gathering
such data. Neither pre- nor post-operative studies have touched to any great extent
on joint replacement in middle age. Gignac et al note the importance of remaining
independent and employed to younger patients with OA, and that the focus in
qualitative literature on functional limitations has not been matched by examination
of impacts on such wider social roles. Since average age in the samples from
studies reviewed above is more than 62 years the majority of participants followed
up after surgery have been retired. As such, this body of work does not substantially
consider the particular impact of joint replacement surgery on OA sufferers’ working
lives. Although an impact on working life has been noted as an issue for younger OA
patients in one focus group study, qualitative studies have not looked in detail at how
barriers to work are experienced by these patients in day-to-day working life and the
patient or the employers’ perspective. Some qualitative research has been
performed to look at expectations and outcomes of knee or hip replacement, in terms
of patient experience. However, we could find no qualitative study that has explored
the employment outcome after joint replacement in the young working-age
population (under 60 years). Qualitative studies have not looked in detail at how
barriers to work are experienced by these patients in day-to-day working life and the
patient or the employers’ perspective. It has repeatedly been found that, prior to
operations, patients in this age group have general and not very clearly formed
visions of post-operative outcomes, and therefore no clear expectations for their
employment.
One of the limitations of our study is the inability to provide evidence for qualitative
work on employment outcome, as there is a lack of studies looking into this aspect of
joint replacement. The studies that have been included suffer from an element of
selection bias, which would be inherent to this type of work.
Qualitative studies would have the scope to identify the barriers that young working-
age patients undergoing joint replacement might face at work before and after
surgery, which cannot be detected by simple quantitative outcome measures. They
would also fulfil arthritis patients’ wishes for richer interaction with researchers in the
gathering of data in this area. It would be interesting to know if there are surgically
modifiable factors, in terms of implant or procedure choice, which may have
implications on this. Indeed there is a possibility that if the patient and employer
expectations are tailored to setting realistic goals, the outcome may be different.
Clearly a qualitative study of the younger working-age population has the potential to
identify factors that might help achieve these goals.
Table 1 summarises the answers to the key questions raised in the review. During
the consenting process patients’ expectations should be explored and addressed as
unrealistic expectations may actually lead to poorer recovery. Surgeons need to be
aware that patients who have been unable to work before surgery and those who
have been on unemployment benefit are unlikely to return to work after their hip or
knee replacement. Younger patients with fewer co-morbidities were more likely to
return to work. Creating a supportive environment at home and work can help
facilitate this. Although majority of the patients can return to the same level, those
involved in heavy manual labour will take longer time.
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Table 1
Answers to key questions
(* to ***) - RCGP 3 star grading of evidence
What are the patient’s expectations from a joint replacement?
Barriers to employment are important factors driving the patients to proceed with
joint replacement surgery(***). Patients have high expectations of the impact of joint
replacement surgery on their ability to work(***). Unrealistic expectations leads to
heightened frustration and slower rate of recovery preventing them from returning to
work.
Who is most at risk of not returning to work after joint replacement surgery?
Patients who were unemployed before surgery are less likely to obtain gainful
employment after surgery and patients who have been off-sick longer preoperatively
were less likely to return to work(***). Motivation is the key factor in early return to
work(**).
What external factors are important to help patients return to work?
Supportive care from healthcare providers and family support after surgery are
helpful in facilitating successful rehabilitation and satisfaction(**). Patients on
benefits are less likely to return to work while self-employed return to work
sooner(***). Patients who are have no restriction on activity following joint
replacement surgery return to work sooner(***).
Do age and co-morbidities of the patient determine their ability/motivation to return to work?
Younger patients and those with less co-morbidities were more likely to return to
work(**).
Are patients able to return to work at the same level?
Majority of the patients are able to return to work at the same level, although patients
involved in heavy manual labour return to work slower, while those with light work
load returned sooner(***).