5/14/24, 4:05 PM The need to address the burden of musculoskeletal conditions - ScienceDirect

Best Practice & Research Clinical Rheumatology

Volume 26, Issue 2, April 2012, Pages 183-224

The need to address the burden of musculoskeletal

conditions
Anthony D. Woolf BSc, MBBS, FRCP a , Jo Erwin MSc, MPH, PhD b 1 , Lyn March MD, MSc, PhD, FRACP, FAFPHM c 2

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Musculoskeletal conditions 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]. Musculoskeletal
conditions 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 of these conditions is therefore predicted to increase, in particular in developing countries. The impact on
individuals and society of the major musculoskeletal conditions is reviewed and effective prevention, treatment and
rehabilitation considered. The need to recognise musculoskeletal conditions as a global public health priority is
discussed.

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

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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].

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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…

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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

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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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