Perceptions of working with chronic knee pain: A qualitative study

Abstract

BACKGROUND:

People with chronic knee pain may opt to continue to work without seeking specific ergonomic adaptations or disclose the existence or severity of their pain to work colleagues or supervisors due to the pressures of maintaining employment. To gain a deep personal perspective on how people with chronic knee pain cope while working [7 , 18], qualitative research methods are a useful way of in encouraging meaningful discussion amongst workers with chronic knee pain of potential work-related strategies to minimize their work-related disability.

OBJECTIVE:

To conduct an in-depth exploration of the impact of chronic knee pain on the working life of selected individuals. The specific aim was to identify barriers and enablers for promoting sustainable work within the work environment following the methodological principles from grounded theory.

METHOD:

Eleven workers with chronic knee pain participated in one of three focus groups (age range 51–77 years). All focus group sessions were audiotaped and transcribed verbatim. Two researchers independently identified themes around the common challenges for continuing employment among older people with chronic knee pain.

RESULTS:

The main themes expressed in these focus groups were: 1) the effect of knee pain on work productivity, 2) strategies to improve work productivity, and 3) future suggestions about sustainable work for older people with chronic knee pain. New insights gained from the focus groups included the extent of physical limitations due to chronic knee pain, lack of ergonomic policies within the workplace, types of work transitions utilized to accommodate knee pain, complexity of disclosure, social support at work, and the unpredictability of future arthritis progression.

CONCLUSION:

This research suggests that in providing the appropriate work environment to enable individuals with knee pain to continue to be productive members of society, workplace strategies are needed to minimize the stigma and encourage communication about chronic knee pain, as well investment in appropriate ergonomic support equipment.

Keywords

Knee osteoarthritis qualitative research worker productivity work transitions

1 Introduction

Chronic knee pain due to osteoarthritis is highly prevalent among people in the workforce aged 50 years and over [1]. Pain and activity limitations from knee problems result in an increase in the number of sick days taken and reduced productivity while at work [2 –6]. People with chronic knee pain may continue to work without seeking specific ergonomic adaptations or disclosing their pain severity to coworkers or supervisors; instead opting to utilize self-managed strategies to try to reduce work-related disability [7]. Furthermore, workers may experience stigma associated with chronic knee pain and may not be willing to reveal this condition due to the pressures of maintaining employment [8]. Globally, with an ageing population, an increase in obesity, and a tendency to delay retirement, the prevalence of people affected by chronic knee pain in the workforce will increase [9].

Occupational risk factors for developing chronic knee pain are well known [10]. The ongoing consequence of working with chronic knee pain and the impact on work productivity has only recently been explored [11]. Reduced work productivity is conventionally quantified as days taken off work (absenteeism) or as self-reported reduced quantity or quality of work done while at work (also referred to as “presenteeism” or “at work productivity loss”) [12, 13]. A recent review found evidence to indicate a positive association between knee pain or knee osteoarthritis and increased work absenteeism. However, there were only a small number of studies evaluating the impact on presenteeism [14].

Additionally, few studies have examined whether demographic, psychological, or workplace factors influence if people with chronic knee pain remain in productive employment [15]. Such factors variously include work support relationships, work health and safety policies, and individual issues such as adaptability or personal coping mechanisms [16]. In summary, as more people are required to extend their employment beyond the traditional retirement age, there is a need to develop effective specific workplace sustainability strategies to allow people with chronic knee pain to remain in the workforce. Focus groups have been used previously to gain a deep personal perspective on how people with musculoskeletal pain cope while working [7 , 18], and such a tool may also be useful in encouraging the in-depth discussion in a group setting of issues as potentially stigmatized as chronic knee pain. However, no studies have specifically investigated such strategies and employer support among working people with chronic knee pain. The aim of this study is to explore the personal perspectives among those people with chronic knee pain with respect to the barriers, concerns, and coping strategies utilized to remain in paid employment.

2 Methods

2.1 Design

In this grounded theory study, focus groups were conducted among participants who currently work with knee pain to explore shared experiences. Focus group methodology was used in order to encourage face-to-face interaction between participants, evolve discussion, and identify shared experiences within a specific timeframe. Recommended optimal group interactions should be between six and eight participants within each focus group [21]. A questionnaire-based survey was completed by all participants six months prior to the focus group discussions. This survey provided quantitative data of participant’s knee pain severity, work productivity, and quality of life.

2.2 Participants

People with chronic knee pain in a working role (including unpaid and paid) who had completed the two-year Long-term Evaluation of Glucosamine Sulphate (LEGS) study (NCT00513422) [19], were invited to participate in this study. Eligible persons were sent an expression of interest letter. Participants were informed that the focus group sessions would be audiotaped and they would be required to attend a one hour session at a choice of one of two metropolitan venues in New South Wales, Australia.

2.3 Procedure

Before the commencement of the focus group discussion, the facilitator described the discussion timeline with the stated objective to casually share any personal experiences or perspectives in regard to chronic knee pain while at work. The facilitator reminded participants this focus group discussion was an open conversation, there were no right or wrong answers, and group members were encouraged to interject at any time. All participants were asked to maintain confidentiality of any information discussed by any of the participants in their focus group, but such confidentiality could not be guaranteed by the researchers. Furthermore, participants were assured that no report will contain any information that would allow an individual participant in the study to be identified. Ethics approval was received from the University of Sydney Human Research Ethics Committee.

Discussion questions were directed by the facilitator and another member of the research team took detailed notes. Techniques constituted by Krueger and Casey [20] were used when conducting focus group discussion, posing questions to the discussants, and using broadly open-ended questions to ensure an exchange of thoughts and matters, and drawing participants into the discussion. The three main key questions posed in the focus groups were related to 1) specific difficulties of working with chronic knee pain, 2) strategies or coping behaviors that make it easier to work with chronic knee pain, and 3) potential work environment changes that may be beneficial for people with chronic knee pain. Questions were similar to previous questions asked by researchers examining problems faced by workers with inflammatory arthritis (see Table 1) [17].

Table 1.
Focus group questions

Question 1: “What makes it difficult for you to continue working while having arthritis?”

[a. Explain how your knee limits your ability to work &b. what concerns you most when working with painful knees?]

Question 2: “What strategies would make it easier for you to work or allow you to work longer?”

[c. Tell us about how your supervisor and/or co-worker have assisted with your knee pain that made it easier/more difficult for you to work with your knees &d. tell us about the modifications you made to help you work?]

Question 3: “Potential work environment changes that may be beneficial for people with chronic knee pain?”

[e. if you could give advice for someone in the same situation as you, what might you suggest?]

When a problem was identified, the facilitator used the fishbone technique to examine the underlying causes of the participant’s problems, such as asking questions until reaching the root of the issue [17]. Focus group discussions were audiotaped and transcribed verbatim, identifying information was removed, and then checked against the recordings for accuracy.

2.4 Data analysis

Principles of grounded theory approach [21] were used. Data was collected, and analysis involved an interactive process to ensure data saturation. To assist us with this process Campo et al. [22] systematic analytical audit trail was used to identify and ensure validity of the thematic codes. The first author (MA) read the transcripts several times to detect broad categorical themes in statements made by participants and developed a coding scheme. Another author (MM) read the transcripts to check the validity of the categorical themes and made suggestions for improvements. All authors meet frequently until a consensus was reached with consistency and transparency in the coding. In the coding scheme, board themes and sub-themes were added. Illustrative quotes were selected from these data (see Fig. 1: Qualitative Research Process).

Fig. 1.

Qualitative research process [adapted from Campo et al. (22)].

2.5 Participant characteristics

Background data collected included age, gender, relationship status, education qualifications, and weekly income. In addition, a number of quantitative measures were undertaken. Physical and mental wellbeing was evaluated using the Medical Outcomes Study Short Form 12 Health Survey (SF-12). The eight health domains are aggregated into two summary measures: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). Both summary scores are population norm-based scores with a mean (sd) of 50(10). A higher score represents better physical and mental well-being [23].

Co-morbidity was reported using the Self-Administered Co-morbidity Questionnaire (SCQ) [24]. This questionnaire recorded the presence of 12 current medical conditions: high blood pressure, heart disease, lung disease, diabetes, ulcer or stomach disease, kidney disease, liver disease, anemia or other blood problems, cancer, depression, back pain, and rheumatoid arthritis. The scores range from 0–36 points, where a higher score indicates more co-morbidity. The co-morbidity score was further categorized into three levels: no co-morbidities, 1–3 co-morbidities, and 4 or more co-morbidities [25]. Maximum knee pain was recorded over a seven day period, participants were required to record daily maximum left knee pain and right knee pain (0–10) [26]. Also recorded was perceived problems with other joints: hips, hands, feet, lower back, or other [27].

Work-related factors were collected including current main occupation including caregiver and volunteer, work status, work abilities related to demands of occupation, and any work transitions or adaptions in the last six months. The 10-item Work Transitions scale evaluated three categories of work transitions due to knee problems 1) occasional loss of work hours or work interruptions, 2) change in the type or nature of work, or 3) permanent changes of work hours. Work Transition scale scores were summed for a total range of 0–10, a higher score indicated more work changes [6, 28].

3 Results

3.1 Participant characteristics

Of seventeen workers with chronic knee pain who expressed initial interest in participating in a focus group discussion, eleven participants attended one of the three focus groups. Reasons for non-attendance by the other six workers were inability to attend due to other commitments, or the travelling distance required. The individual groups consisted of 3, 4, and 4 participants. Participants were working full time (5), part-time (4), were paid caregivers (1), or volunteer workers (1) (>24 h/week) and they were aged 51–77 years, (mean age: 60.6±7.8 years) (see Tables 2 & 3).

Table 2.
Participants involved in focus group

Participant Identifier Gender Occupation Age

1. Male School Crossing Supervisor 56

2. Female Pool lifeguard Casual 55

3. Male School Teacher 59

4. Male Stock Controller P/T 65

5. Female Volunteer (Unpaid) 77

6. Female Librarian 58

7. Female Manager Administrator 67

8. Female Caregiver (Unpaid) 68

9. Female Registered Nurse 50

10. Male Librarian/Student 60

11. Female Midwife 51

Participant Identifier	Gender	Occupation	Age
1.	Male	School Crossing Supervisor	56
2.	Female	Pool lifeguard Casual	55
3.	Male	School Teacher	59
4.	Male	Stock Controller P/T	65
5.	Female	Volunteer (Unpaid)	77
6.	Female	Librarian	58
7.	Female	Manager Administrator	67
8.	Female	Caregiver (Unpaid)	68
9.	Female	Registered Nurse	50
10.	Male	Librarian/Student	60
11.	Female	Midwife	51

Table 3

Participant Demographics (n = 11)

	Mean (sd)	Nn(%)
Age (years)	60.6 (7.8)
45–54		2 (9)
55–64		5 (46)
65–100		4 (36)
Gender (Women)		7 (64)
Relationship Status
Single or Widowed		4 (36)
Married or Cohabiting		7 (64)
Education Qualifications
Tertiary Education		3 (27)
Weekly Income
Low ($0–$1,000)		5 (46)
Medium/High (> $1,000)		5 (46)
Preferred Not To Answer		1 (9)
SF-12 PCS	47.0 (6.8)
SF-12 MCS	50.7 (9.8)
Perceived Problems with Other Joints
None		4 (36)
Lower Back		4 (26)
Hands		3 (27)
Hips		2 (18)
Feet/Ankles		2 (18)
Co-Morbidity (Score 0–36)	2.6 (3.0)
0		4 (36)
1–3		4 (36)
4 or more		3 (27)
Knee Pain Score (0–10)	3.0 (2.6)
0–2		4 (36)
3–10		7 (64)
Current Main Occupation
Professional		7 (64)
Semi Manual/Manual		4 (36)
Work Status
Full time		5 (46)
Part time/Volunteer/Caregiver		6 (55)
Demands of Occupation
Mainly Mental		2 (18)
Both Mental &Physical		9 (82)
Work Transitions Last 6 months (1 or more)		4 (36)

Three overarching broad themes were identified in the analysis: 1) barriers to work productivity due to knee pain, 2) strategies to improve work productivity, and 3) future recommendations about sustainable work for people with chronic knee pain. One hundred and fifty-five items were identified from the focus discussions which related to perceived barriers to work productivity due to knee pain. These barrier items were subsequently subdivided into three broad sub-themes: 1) symptoms and characteristics of chronic disease, 2) working conditions, and 3) psychosocial work factors (see Fig. 2). One hundred and seventeen items were identified which related to strategies used by participants to improve productivity (see Fig. 3). In addition, eleven items were identified which related to future workplace recommendations for sustainable work (see Fig. 4).

Fig. 2.

Diagram of thematic items from focus group: Barriers.

Fig. 3.

Diagram of thematic items from focus group: Strategies.

Fig. 4.

Diagram of thematic items from focus group: Future recommendations.

3.2 Barriers to work productivity

3.2.1 Symptoms and characteristics of chronic disease/knee pain

Participants, engaged in each type of work represented in the focus groups, expressed common symptoms or characteristics of osteoarthritis. Acceptance of the disease progression of the knee joint was voiced by all participants regardless of work status, whether in full or part-time work or a volunteer but they universally saw chronic knee pain as part of “old age” [RN] or “being older” [MJ]. Additionally, the majority of participants were conscious of their knee, especially among those who had bilateral knee pain, and were able to identify which knee was the main limitation to continued working: “it’s my right. worse than the left knee” [RN] or “my right knee… actually quite good, it’s my other knee which needs surgery, it’s painful” [CB]. They tend to compensate using the better knee when conducting work, understanding the limitations due to pain.

Only one person reported experiencing knee pain causing fatigue which affected ability to work. This participant (>65 years old) had the least amount of social support at work and little flexibility with work tasks and working hours. The participant indicated fatigue was “draining every bit of energy out of my knees” [OW] and during leisure time the knee pain would “catch up”. Physical limitations at work were the third most common issue expressed in relation to knee symptoms. Limitations expressed by the focus groups included walking with difficulty at work and inability to commence a task due to the hesitation about the onset of pain or painful knees slowing down work pace.

Some participants discussed the differences between responses to knee pain compared to pain in other joints. Two participants [CW& JG] expressed more concern or “priority” [CW] for other joints such as the ankle or the back, while the knee was being “compensated” [JG]. Other participants considered their knees were “a small thing not to worry about” [MC] or “a funny joint” [CW] concluding that as a final resort the joint can be “surgically replaced” [RG & CW].

Most participants chose to “avoid” [CB] pain medication or “wouldn’t normally take (pain medication)” [JG]. Participants preferred to “struggle on” [JG] and only resort to pain medication management if needed to get through to the end of the working day. Two participants discussed concern about pain medication management and the issue of side effects due to co-existing conditions with kidney or heart disease. A familiar sub-theme among all focus groups was a person’s self-responsibility regarding “controlling” knee pain [WG] by “keeping weight down” [RN], recognizing the consequence of carrying “extra weight” [JG] to the knee joint as “taking a toll on the body” [JG].

3.2.2 Working conditions

Physical Job Demands

The most concerning issues expressed by participants impacting work was the difficulty experienced in using stairs in the workplace, prolonged standing or sitting, kneeling and bending, or lifting. Only a few participants expressed an inability to take breaks or pauses at work, while the majority expressed their work ethic of “getting on with it” [OW]. Only one participant’s physical workload required manual handing and repetitive manual tasking, while other participants were able to perform tasks differently or had some control over tasks to accommodate for knee pain.

Job Accommodations

A common sub-theme of working conditions expressed by all the focus groups was the lack of health and safety policies within the workplace to assist workers with chronic knee pain. All participants adopted their own personal strategies to help cope with knee pain while working. Only one participant, a registered nurse, had the appropriate health and safety procedures embedded into her daily tasks and was aware of their protective implications.

Work Transitions

Of the eleven participants, only one had actually changed career due to his knee condition, moving from running a family business restaurant to an office job that was more sedentary, stating “I had to give it up, I could hardly walk”, “I’d gone back to my old job that I was there for 25 years”. Some participants discussed an increased need for recovery during or at the end of work, by “sitting down for an hour” [MC] or asking coworkers during working hours “do you mind if I sit down, knee is giving me a bit of pain” [JG]. Of these participants, most would recover at home using their own individual approaches such as “lifting legs above waist” [MJ], or using “compression stockings” [MJ]. There was some discussion among all focus groups concerning the avoidance of certain work tasks to accommodate for their knee pain. One participant compared the change in job tasks and responsibilities over a five-year period, by consciously “choosing” work tasks causing less strain on the knees [OW]. Another participant simply “avoided other stuff” [WM], while three participants discussed how their knee condition had changed the way they conducted themselves at work such as by “not being as interactive” [RN] because of pain associated limitation in the knee joint(s).

3.2.3 Psychosocial work factors

Social Support

One interpersonal barrier identified by participants was a lack of understanding, empathy, and support among supervisors for their knee problems, even when discussing forms of adaptation in the work environment. For example, as one participant indicated when asked about the response of management, “they didn’t, they said “just do it” [OW]. Participants expressed reluctance to being open about knee pain, flare ups, and the impact on work productivity. This itself was more of a challenge than the knee pain itself, “worry about disrupting other people” [OW] if they decided to disclose condition to others during working hours. One participant concerned with disclosing the condition to others had the risk of being stigmatized because of the disease’s “invisibility”, stating, “it’s reverse discrimination but how can you beat it? You can’t physically say ‘here’s my pain’ and look at it even though it hurts. But there are a lot of people out there who rort 1 the system and ruin it for anyone else who is genuinely in pain. I’ve got a disability thing for my car. I try not to use it because sometimes people say ‘Oh, you’re not in a wheelchair, why do you need it?” [RN].

Individual

Participants universally expressed that they felt an insecurity or inability of continuing to work with knee pain. The majority of participants expressed concern about getting older, slowing down, the (lack of) health of their knees, and limited employment opportunities. “Then there’s a climate of all of us having to work longer and you’re worried your knees are going to prevent it, because I am slowing down because of my knees and my (job) opportunities are limited” [WG].

Only one participant discussed how his knees would affect the quality of his retirement: “I think for me it’s how it’s going to interrupt my retirement. I can see me getting through the work years and maybe adjusting, doing minor adjustments but it’s those post-work years when you do start to age that’s when you think hmm, will I be able to do this, this and this? What do you have to modify?” [RN].

Most of the participants discussed the unpredictability of future progression of their chronic knee pain. Some were “worried” [OW & CB], “irritated” [MC], or “annoyed” [RN] stating the condition was “going to get worse” [WG] or questioning “does this health situation get any better? No. I don’t think so” [OW] and “living on borrowed time” [RG]. Again, the common theme of self-managing chronic knee pain was raised as being more proactive in “protecting own health and self-preserving joints” [JG] by changing “my life and how I live” [JG].

The majority of participants discussed the possibility of having knee surgery, with total knee replacement as the last option or “somewhere down the track” [JG].“see, for knees you can have total knee replacements. There is a surgical intervention that makes you feel ten years younger and there’s no pain so for other conditions there’s not that thing and not being concern with risk of surgery ….risk of surgery, 1 in a 1000” [CW].

3.3 Strategies to improve work productivity

The second major theme identified in the analysis related to how participants modified work to help manage knee pain and work productivity. Six strategies were identified by participants to improve productivity while working with knee pain. These strategies were (1) changing the way they do work, (2) using aids, (3) getting help from coworkers, (4) benefits of being a mature/experienced older worker, (5) cognitive mechanisms, and (6) self-managed treatment and prevention (see Fig. 3). Changing the way they do work was the most cited strategy because participants developed individual strategies to help make work easier. For example, participants altered posture by sitting down when conducting tasks, standing only when required, or bending the trunk when squatting instead of flexing the knees, or taking more time when conducting tasks, especially when carrying heavy items.

All participants had accepted the need to “come up with strategies” [CB] and reorienting tasks to suit their knees, “you can do it in lots of different ways” [JG], “as long as they see you being productive” [CB]. Only one participant had flexible work arrangements regarding orientation to tasks and arrival or departure from work.

The main aids available at work to help support knees after long periods of standing were either stools [JG] or chairs [MJ]. Support afforded by stair rails, ramps, or access to lifts were used when required to walk between floors at work. Some participants described using pieces of clothing or pads when kneeling to the floor to cushion their knees. Participants who had both back and knee pain used the aid of shoe inserts or back brace while at work, with the aim of supporting both their back and knees.

As earlier mentioned, despite social support acting as a barrier, from this discussion group, social support also acts as a strategy that has assisted some participants, especially support coming from coworkers. For instances, all participants would openly express to other coworkers particularly, younger coworkers, about their knee pain “I need to take a break now because my legs are hurting” [JG]. Some participants felt their personal commitment and professional maturity in the workplace gave them confidence when asking for relief from unmanageable physical demanding activities at work, “…we wouldn’t be afraid to say “hey…. this is a bit much for our knees can we put this off until tomorrow? [RN], “I think as you get older it’s easier to say no” [CB] or “I got to the point in the workplace I kind of say what I feel these days” [JG].

Another common work coping strategy used by participants was utilizing various cognitive mechanisms such as distraction and self-talk. Coping mechanisms included focusing on job tasks, ignoring the symptoms, and distraction through constant movement. Self-talk included “I suppose you adapt to it” [RN] or most commonly, “you’ve got to keep moving otherwise you’ll lose it” [MJ]. Some of the participants used self-directed treatment and prevention strategies to manage pain symptoms via conventional and alternative therapies. For instance, the use of aids such as support stockings, applying ice, and use of a support pillow at work to relieve knee pain were some self-treatments used by these participants. Others used supplements such as glucosamine for pain relief. Only one participant used a non-steroidal anti-inflammatory drug for pain relief, having some health literacy regarding medication dosage, side effects, and effectiveness. Conversely, having limited health literacy about medication use was expressed by other participants in the two focus groups including issues such as being unclear about the correct dosage for pain relief and effects of some common arthritic drugs.

3.4 Future recommendations

The third major theme identified in the analysis related to participant responses of a hypothetical question concerning potential work environment changes that may be beneficial for people working with chronic knee pain. Participants’ suggestions to reduce future work disability and increase work productivity were for employers to provide sitting apparatus or better ergonomic chairs in the workplace, “I’d change the chairs… That’s the only thing I could suggest that could be done differently. I don’t think I’d be happy if they asked me to buy my own but …” [MC]. Other suggestions were to provide workers with various forms of exercise at work such as meditation, Pilates, yoga, or swimming, “…if there’s some physical activity or exercising in the workplace it breaks the routine” [WG]. Another suggestion was to consult and then respond to employee suggestions about designing the workspace and work tasks, “we didn’t have very much input to the layout of the ward. We’d had the opportunity … but it wasn’t taken advantage of so there was very little input form the staff that were (going to be) working there” [JG].

4 Discussion

This focus group research has provided a novel insight into the challenges and strategies used by workers with chronic knee pain to achieve sustainable work productivity. The analysis suggests a number of barriers to work productivity including symptoms and characteristics of chronic knee pain, reluctance to use analgesics due to perceived risk of side effects, physical job demands, lack of availability to ergonomic modifications, and psychosocial factors such as lack of understanding and support from work colleagues, reluctance to disclose personal information about knee pain, and future uncertainty regarding ability to work with more severe knee pain. Workers referred to a number of self-management strategies to better cope with these challenges at work such as using self-developed aids, use of lift or ramps, use of chairs or stools, and asking assistance from coworkers. Cognitive coping mechanisms included the use of distraction and self-talk. Issues of concern raised in the focus groups included the lack of health literacy about medication use for chronic pain, the ‘invisibility’ of this condition, and the lack of ergonomic assessments carried out in the workplace to assist workers with disability or chronic knee pain.

Most participants expressed acceptance of their knee condition and self-efficacy due to their desire to maintain work. It seems self-efficacy beliefs appear to be most important in determining functionality when challenged by limitations in knee function [29]. The most challenging barrier at work was needing to use stairs in the workplace, followed by prolonged standing or sitting, kneeling or bending [2, 30].

Another common talking point was the dependency on social support at work which at times was a challenge for these workers with chronic knee pain. Many of the participants depended on the support of co-workers to conduct certain tasks. Receiving support from co-workers has been identified as benefiting work productivity among people with various musculoskeletal conditions, [5 , 32], one study found co-worker support contributes in maintaining employment for up to two years [33]. Social support at work is a complex issue and largely depends upon the individuals’ openness about their condition to others, the degree of empathy from co-workers and managers, and the persons’ emotional needs. Focus group participants felt that disclosing knee condition to co-workers and supervisors was not in their best interest. Similar to other studies examining work difficulties among people with inflammatory arthritis [17], our study illustrated individuals felt a lack of support for their condition among co-workers and supervisors. There were difficulties associated with disclosing the condition to others. They discussed the consequences associated with disclosing personal medical information and the feeling of being stigmatized as a consequence in the act of disclosing. For the majority of discussants, there were additional difficulties with the unknown consequence of response. On the other hand, not disclosing their knee condition to others could prevent access to beneficial preventative strategies.

As a first step in implementing tangible measures to address this issue, efforts need to encourage people with knee pain to be open about their condition within the workplace without the threat of loss of employment or demotion. Changes participants wanted to see in their workplaces included access to or more opportunities for physical activity at work, availability of ergonomic assessments with appropriate apparatus, and consultation in designing the workspace. Similar to the finding of another study [7], participants in this study valued workplace interventions that incorporated access to physical activity at work such as swimming, meditation, or Pilates. Our study illustrated the difficulties participants experienced obtaining ergonomic modifications to help cope with pain at work. There is an association between ergonomic modifications and reduced work disability [17 , 35]. In particular, a Danish study examined the effect of participatory ergonomics among 292 floor layers and found a reduction in self-reported knee pain with unchanged levels of work productivity over a 12-month follow-up period. The study’s participatory ergonomic program included introducing participants with knee pain to new ways of for performing a work task by utilizing alternative standing positions rather than the traditional kneeling positions [34]. An effective workplace strategy for persons with chronic knee pain would include developing an intervention program (similar to above) [34] involving ergonomic assessments and modifications of work equipment [34], adapting workstations [17], and changing the organizational culture and physical environment by introducing flexible work arrangements [35] and active rest breaks [35].

Our focus group methodology provided novel insight into the work problems experienced by older people with chronic knee pain by enabling individuals to openly discuss concerns amongst peers. A limitation to this study was the small number of participants (ranging from three to four in each focus group), compared to the recommended number of six to eight [21]. The average number of focus group participants in previous published studies was 8.4 participants per group, ranging from 1 to 96, with a median of 5 [36]. Our smaller group size possibly limited the variability of employment type and the severity of chronic knee pain amongst study participants. The smaller focus groups in our study may have been as a result of sourcing participants from an existing, readily available sample of individuals’ who were well experienced with the phenomenon of interest (nonprobability purposive sample), rather than recruiting from the general population. However, despite our small focus groups, we were still able to achieve data saturation.

Our aim was specifically to examine knee function during work; we did not investigate the spillover effect of knee pain into other social roles such as taking care of family, work and life balance, or financial concerns [7]. The perspective of the employer is lacking, and it would be useful to examine their attitudes and knowledge of the means to dealing with the needs of workers with knee pain. Another issue recognized in this focus group and also previously raised by other researchers [18] is the chronic condition of knee pain tends to be overshadowed as a part of normal ageing, rather than a condition of biological disruption or an illness requiring treatment [37]. As our study participants expressed, there is no need to manage chronic knee pain because it is a part of “normal” ageing and a knee can be replaced. The need to get on with day-to-day life makes the condition invisible and the medical importance is lessened by the person who has chronic knee pain. However, the chronic condition changed the way participants perceive and conduct their work.

To conclude, it is hoped these everyday accounts of workers with chronic knee pain will guide intervention programs and future studies will focus on problems of greatest importance to workers [8]. Our findings illustrate, difficulties experienced by workers with chronic knee pain are inadequately addressed in the workplace. Also, attention needs to focus on enabling and encouraging workplace support for workers who choose to disclose a condition to others. The workplace must minimize stigmatization and allow for job security. There is need to make ergonomic adjustments in the workplace. Additionally, health and safety issues must be addressed with input from employees in order to reduce the barriers experienced among workers with chronic knee pain.

Conflict of interest

None to report.

Footnotes

Rort (a noun, informal, Australian/New Zealand) is defined as: ‘a fraudulent or dishonest act or practice’. Cambridge Dictionary. [Internet] 2018 [updated 2018; cited 2018 Jan 16]; Available from:

Acknowledgments

We thank the LEGS participants for their contributions to our research. This work was supported by Arthritis Australia (The Kevin R. James Grant) awarded to Dr Maria Agaliotis.

References

Busija

, Bridgett

, Williams

SRM

, Osborne

, Buchbinder

, March

, et al. Osteoarthritis. Baillieres Best Pract Res Clin Rheumatol. 2010;24(6):757–68.

Gobelet

, Luthi

, Al-Khodairy

, Chamberlain

. Work in inflammatory and degenerative joint diseases. Disabil Rehabil. 2007;29(17):1331–9.

Lerner

, Amick

3rd , Rogers

, Malspeis

, Bungay

, Cynn

. The work limitations questionnaire. Med Care. 2001;39(1):72–85.

Sadosky

, Bushmakin

, Cappelleri

, Lionberger

. Relationship between patient-reported disease severity in osteoarthritis and self-reported pain, function and work productivity. Arthritis Res Ther. 2010;12(4):R162.

Alexopoulos

, Tanagra

, Detorakis

, Gatsi

, Goroyia

, Michalopoulou

, et al. Knee and low back complaints in professional hospital nurses: Occurrence, chronicity, care seeking and absenteeism. Work. 2011;38(4):329–35.

Gignac

, Cao

, Lacaille

, Anis

, Badley

. Arthritis-related work transitions: A prospective analysis of reported productivity losses, work changes, and leaving the labor force. Arthritis Rheum. 2008;59(12):1805–13.

Kaptein

, Backman

, Badley

, Lacaille

, Beaton

, Hofstetter

, et al. Choosing where to put your energy: A qualitative analysis of the role of physical activity in the lives of working adults with arthritis. Arthritis Care Res. 2013;65(7):1070–6.

Tveito

, Shaw

, Huang

, Nicholas

, Wagner

. Managing pain in the workplace: A focus group study of challenges, strategies and what matters most to workers with low back pain. Disabil Rehabil. 2010;32(24):2035–45.

Woolf

, Pfleger

. Burden of major musculoskeletal conditions. Bull World Health Organ. 2003;81(9):646–56.

10.

Fransen

, Agaliotis

, Bridgett

, Mackey

. Hip and knee pain: Role of occupational factors. Best Pract Res Clin Rheumatol. 2011;25(1):81–101.

11.

Tang

, Escorpizo

, Beaton

, Bombardier

, Lacaille

, Zhang

, et al. Measuring the impact of arthritis on worker productivity: Perspectives, methodologic issues, and contextual factors. J Rheumatol. 2011;38(8):1776–90.

12.

McKevitt

, Morgan

, Dundas

, Holland

. Sickness absence and ‘working through’ illness: A comparison of two professional groups. J Public Health Med. 1997;19(3):295–300.

13.

Aronsson

, Gustafsson

, Dallner

. Sick but yet at work. An empirical study of sickness presenteeism. J Epidemiol Commun H. 2000;54(7):502–9.

14.

Agaliotis

, Mackey

, Jan

, Fransen

. Burden of reduced work productivity among people with chronic knee pain: A systematic review. Occup Environ Med. 2014;71(9):651–9.

15.

Aronsson

, Gustafsson

. Sickness presenteeism: Prevalence, attendance-pressure factors, and an outline of a model for research. J Occup Environ Med. 2005;47(9):958–66.

16.

Gosselin

, Lemyre

, Corneil

. Presenteeism and absenteeism: Differentiated understanding of related phenomena. J Occup Health Psychol. 2013;18(1):75–86.

17.

Lacaille

, White

, Backman

, Gignac

. Problems faced at work due to inflammatory arthritis: New insights gained from understanding patients’ perspective. Arthritis Rheum. 2007;57(7):1269–79.

18.

Ong

, Jinks

, Morden

. The hard work of self-management: Living with chronic knee pain. Int J Qual Stud Health Well-being. 2011;6(3).

19.

Fransen

, Agaliotis

, Nairn

, Votrubec

, Bridgett

, Su

, et al. Glucosamine and chondroitin for knee osteoarthritis: A double-blind randomised placebo-controlled clinical trial evaluating single and combination regimens. Ann Rheum Dis. 2015;74(5):851–8.

20.

Krueger

, Casey

. Focus groups: a practical guide for applied research (3rd ed). Sage Publications, Thousand Oaks, Calif, 2000.

21.

Glazer

. The Discovery of Grounded Theory: Strategies for Qualitative Research. Strauss Chicago, IL: Aldine Press Inc; 1967.

22.

Campo

, Darragh

. Impact of work-related pain on physical therapists and occupational therapists. Phys Ther. 2010;90(6):905–20.

23.

Sanderson

, Andrews

. The SF-12 in the Australian population: Cross-validation of item selection. Aust NZ J Publ Heal. 2002;26(4):343–5.

24.

Sangha

, Stucki

, Liang

, Fossel

, Katz

. The Self-Administered Comorbidity Questionnaire: A new method to assess comorbidity for clinical and health services research. Arthritis Rheum. 2003;49(2):156–63.

25.

Reichmann

, Katz

, Kessler

, Jordan

, Losina

. Determinants of self-reported health status in a population-based sample of persons with radiographic knee osteoarthritis. Arthritis Rheum. 2009;61(8):1046–53.

26.

Lequesne

. Indices of severity and disease activity for osteoarthritis. Semin Arthritis Rheum. 1991;20(6 Suppl 2):48–54.

27.

Agaliotis

, Fransen

, Bridgett

, Nairn

, Votrubec

, Jan

, et al. Risk factors associated with reduced work productivity among people with chronic knee pain. Osteoarthritis Cartilage. 2013;21(9):1160–9.

28.

Gignac

MAM

, Badley

, Lacaille

, Cott

, Adam

, Anis

. Managing arthritis and employment: Making arthritis-related work changes as a means of adaptation. Arthritis Rheum. 2004;51(6):909–16.

29.

Rejeski

, Miller

, Foy

, Messier

, Rapp

. Self-efficacy and the progression of functional limitations and self-reported disability in older adults with knee pain. J Gerontol B Psychol Sci Soc Sci. 2001;56(5):S261–5.

30.

Allen

, Chen

, Callahan

, Golightly

, Helmick

, Renner

, et al. Associations of occupational tasks with knee and hip osteoarthritis: The Johnston County Osteoarthritis Project. J Rheumatol. 2010;37(4):842–50.

31.

Tuomi

, Ilmarinen

, Martikainen

, Aalto

, Klockars

. Aging, work, life-style and work ability among Finnish municipal workers in 1981-1992. Scand J Work Environ Health. 1997;23(Suppl 1):58–65.

32.

Macfarlane

, Pallewatte

, Paudyal

, Blyth

, Coggon

, Crombez

, et al. Evaluation of work-related psychoso-cial factors and regional musculoskeletal pain: Results from aEULAR Task Force. Ann Rheum Dis. 2009;68(6):885–91.

33.

Yelin

, Sonneborn

, Trupin

. The prevalence and impact of accommodations on the employment of persons 51-61 years of age with musculoskeletal conditions. Arthritis Care Res. 2000;13(3):168–76.

34.

Jensen

, Friche

. Effects of training to implement new tools and working methods to reduce knee load in floor layers. Appl Ergon. 2007;38(5):655–65.

35.

Gallis

. Work-related prevalence of musculoskeletal symptoms among Greek forest workers. Int J of Ind Ergonom. 2006;36(8):731–6.

36.

Carlsen

, Glenton

. What about N? A methodological study of sample-size reporting in focus group studies. BMC Medical Research Methodology. 2011;11(1):26.

37.

Gignac

, Davis

, Hawker

, Wright

, Mahomed

, Fortin

, et al. “What do you expect? You’re just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum. 2006;55(6):905–12.