3The need to address the burden of musculoskeletal conditions
Introduction
Musculoskeletal conditions (MSCs) are common in men and women of all ages across all socio-demographic strata of society. They are the most common cause of severe long-term pain and physical disability and affect hundreds of millions of people around the world. They impact on all aspects of life through pain and by limiting activities of daily living typically by affecting dexterity and mobility. They affect one in four adults across Europe [1]. MSCs have an enormous economic impact on society through both direct health expenditure related to treating the sequelae of the conditions and indirectly through loss of productivity. The prevalence of many of these conditions increases markedly with age, and many are affected by lifestyle factors, such as obesity and lack of physical activity. The burden is therefore predicted to increase, in particular in developing countries. The enormous and growing impact of MSC on individuals and society is not however widely recognised at the level of health policy or priority.
There are several possible reasons for the lack of priority for prevention or management of these conditions. One reason is that MSCs are a diverse group of disorders with regard to pathophysiology, although they are linked anatomically and by their association with pain and impaired physical function. They encompass a spectrum of conditions, including inflammatory diseases such as rheumatoid arthritis (RA) or gout; age-related conditions such as osteoporosis (OP) and osteoarthritis (OA); common conditions of unclear aetiology such as back pain and fibromyalgia; and those related to activity or injuries such as occupational musculoskeletal disorders (MSDs), sports injuries or the consequences of falls and major trauma. Some are of acute onset and short duration but many are recurrent or lifelong disorders.
Another reason for the lack of prioritisation is that they are associated with high morbidity but low mortality and current WHO priority for non-communicable diseases [2] is focussing on those that account for the highest burden measured by disability adjusted life years (DALYs) – a measure that is biased towards conditions with high mortality. This results in MSCs and other conditions with high morbidity but low mortality being relatively ignored.
A third reason is that because of their ubiquitous nature, association with ageing and pain and because most conditions do not affect more vital aspects of life benign acceptance of these conditions even among affected individuals.
While no cures exist, for the majority of MSCs there has been an there tends to be a expansion of medical and surgical management techniques that have the ability to control diseases, to reduce pain and avoid years of life lived with disability. Lack of priority for prevention and effective management is now resulting in unnecessary irreversible disability that puts a burden on individuals, their families and carers and society.
A global alliance has been brought together by the Bone and Joint Decade to promote musculoskeletal health and raise priority for the prevention and management of these conditions. One way of achieving this is to provide the evidence of what the burden is, what can be achieved with current knowledge, what is being currently achieved and to highlight the gaps in our knowledge as well as the gaps in the implementation of current best practice. Then, with appropriate priority and resources these gaps can be closed. The Bone and Joint Monitor Project [3] has been providing this evidence through a series of inter-related projects. The burden of MSCs was revised at the start of the Bone and Joint Decade in 2000 [4] and is currently undergoing a further revision. An atlas of musculoskeletal health in Europe is being developed in the EUMUSC.NET Project [5]. In the USA an atlas has been produced of the burden of MSCs [6]. Strategies for prevention and control of the major MSCs based on best-available evidence and best practice were developed in the Bone and Joint Health Strategies project [3]. Standards of care for people with OA and RA along with health-care quality indicators for service providers are being developed in the EUMUSC.NET Project [5]. Surveys have shown how best practice is not being delivered to many [7].
Recognising the impact of these conditions is key to the argument for prioritising prevention, management and research. For this purpose all conditions and injuries that affect musculoskeletal health need to be considered together as they have a common effect on individuals. Data will be presented on the framework proposed by ourselves in a previous issue [8]. The data are predominantly drawn from the work done to revise the global burden of MSCs and from the EUMUSC.NET Atlas of Musculoskeletal Health in Europe *[5], *[8]. Further data and downloadable figures are available at EUMUSC.NET [5].
Section snippets
Measuring the burden of MSCs
The impact of MSCs needs to be measured in terms of the problems associated with them, that is, the pain or physical disability related to the musculoskeletal system, and also in relation to the cause, such as joint or bone disease or trauma. Often a precise cause is unknown, but those people still suffer a significant impact that must not go unmeasured. There are complexities in measuring the burden on societies in a way that is comparable across and between populations. Mortality is still
Incidence and prevalence
Musculoskeletal pain is very common. A review of prevalence studies indicated that in adult populations almost one-fifth reported widespread pain, one-third shoulder pain and up to one-half reported low back pain (LBP) in a 1-month period [18]. In a study of women working in small-scale agriculture in South Africa, 67% reported having chronic musculoskeletal pain [19]. The most common musculoskeletal pain experienced is back pain; pain is the most prominent symptom in most people with arthritis
Incidence and prevalence
OA is the most common joint disorder and accounts for more disability among the elderly than any other disease. OA case definition can be based on pathological changes seen on X-ray, by the presence of joint symptoms or both. It can also be related to the joints affected.
These radiological changes can be graded, usually by Kellgren & Lawrence scores. A Kellgren & Lawrence score of 2–4 is the most widely used definition of radiological OA in epidemiological studies to estimate prevalence of OA
Incidence and prevalence
Rheumatoid arthritis (RA) is the most common inflammatory disease of the joints. The most widely used classification criteria are those from the American College of Rheumatology (ACR) [83]. A more recent up date to this is the EULAR/ACR 2010 classification criteria for RA [84]. Estimating the incidence of RA is problematic due to the delay between patients experiencing symptoms and seeking medical help for these symptoms. This is a problem as the ACR criteria depend on the time elapsed between
Incidence and prevalence
LBP is a major health and socioeconomic problem in Europe. Many people will experience one or more episodes of LBP in their lives. LBP is usually defined as pain localised below the line of the 12th rib and above the inferior glutaeal folds, with or without leg pain. It is usually classified as being ‘specific’ (i.e., associated with a known underlying pathology) or ‘non-specific’. Non-specific LBP accounts for about 90% of cases. It is usually classified according to duration and recurrence:
Incidence and prevalence
OP is defined as “a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk” [162]. Clinically, OP is recognised by the occurrence of characteristic low-trauma fractures, the best documented of these being hip, vertebral and distal forearm fractures. OP and associated fractures are an important cause of morbidity and mortality.
The incidence of OP is best measured
Incidence and prevalence
There is a wide spectrum of trauma and injuries that affect the musculoskeletal system. Injuries often occur in the workplace or are sports related. These injuries have not only short-term but also long-term effects, for example, they may increase the risk of OA in later life. In the US, it estimated that between 60 and 67% of the total injuries that occur annually involve the musculoskeletal system [6].
The Global Burden of Disease project has collected data on the incidence of non-intentional
How to address the burden: strategies to prevent and control MSCs
The impact of MSCs must be recognised in order to gain priority but in addition there must be evidence of cost-effective interventions for prevention and control for there to be the possibility of actions to address this burden. The European Action Towards Better Musculoskeletal Health [184] has developed evidence-based strategies to prevent musculoskeletal problems and to ensure that people with MSCs enjoy a life with fair quality as independently as possible. This was the outcome of the Bone
Conclusion
MSCs have a huge impact on the health and economic well-being of individuals and society. There are strategies to tackle the burden of MSCs, the challenge is to raise the priority of MSCs so that these strategies are widely and effectively implemented. Evidence of the impact on individuals and society and what can be achieved not only in terms of reducing morbidity but also in terms of economic impact and the cost-effectiveness of these strategies is key to bringing about change. As there is
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