Musculoskeletal health

Musculoskeletal health means more than the absence of a musculoskeletal condition. Good musculoskeletal health means that the muscles, joints and bones work well together without pain and requires multiple factors to come together to achieve this ( Fig. 1 ). People with good musculoskeletal health can carry out the activities they want to with ease and without discomfort. It is possible to have poor musculoskeletal health without having a specific musculoskeletal condition.

Factors comprising musculoskeletal health.

Musculoskeletal conditions

Broadly, three groups of musculoskeletal conditions can affect people leading to poor musculoskeletal health . The commonest group comprises conditions of musculoskeletal pain such as osteoarthritis and back pain. Major risk factors for this group include obesity, physical inactivity and injury, all of which are amenable to public health interventions. A second group is osteoporosis and its major consequence, fragility fractures. The risk factors are varied and complex, but many are lifestyle associated, such as smoking, alcohol, poor nutrition and low levels of physical activity. The rarer inflammatory disorders such as rheumatoid arthritis form a third group and are less strongly related to lifestyle, but nonetheless have some important modifiable risk factors, such as smoking.

Much is known about the potentially modifiable risk factors for musculoskeletal ill health ( Table 1 ). Some, such as injury prevention, workplace factors and vitamin D levels , relate to specific conditions. Others, such as obesity and physical inactivity, are more generic in their influence on health and are shared with many other long term conditions .

What is public health?

The practice of public health aims to promote health, prevent disease and prolong life for the whole population through the organised efforts of society to provide an environment in which people can be healthy.

Three public health functions come together to work towards providing the conditions for healthy living ( Fig. 2 ). Health promotion enables people to take steps to maintain and improve their own health and wellbeing, including nutrition and physical activity. As well as supporting individual behaviour change, health promotion activities address social and environmental factors that affect individual health choices. Health protection approaches work to remove threats to health from the external environment, for example from infection, poisoning or injury, including falls and workplace injury. There is a also health services role for public health in developing, planning, implementing and evaluating the services needed by a population, including occupational health services.

What is public health?

Two further public health functions support the above roles. First, collection, interpretation and publication of data to monitor health trends and health needs and inform public health activities. Second, the formulation and evaluation of policies to create the conditions in which people can become healthy, addressing the determinants of health and health inequalities.

Musculoskeletal health

Musculoskeletal health means more than the absence of a musculoskeletal condition. Good musculoskeletal health means that the muscles, joints and bones work well together without pain and requires multiple factors to come together to achieve this ( Fig. 1 ). People with good musculoskeletal health can carry out the activities they want to with ease and without discomfort. It is possible to have poor musculoskeletal health without having a specific musculoskeletal condition.

Factors comprising musculoskeletal health.

Musculoskeletal conditions

Broadly, three groups of musculoskeletal conditions can affect people leading to poor musculoskeletal health . The commonest group comprises conditions of musculoskeletal pain such as osteoarthritis and back pain. Major risk factors for this group include obesity, physical inactivity and injury, all of which are amenable to public health interventions. A second group is osteoporosis and its major consequence, fragility fractures. The risk factors are varied and complex, but many are lifestyle associated, such as smoking, alcohol, poor nutrition and low levels of physical activity. The rarer inflammatory disorders such as rheumatoid arthritis form a third group and are less strongly related to lifestyle, but nonetheless have some important modifiable risk factors, such as smoking.

Much is known about the potentially modifiable risk factors for musculoskeletal ill health ( Table 1 ). Some, such as injury prevention, workplace factors and vitamin D levels , relate to specific conditions. Others, such as obesity and physical inactivity, are more generic in their influence on health and are shared with many other long term conditions .

What is public health?

The practice of public health aims to promote health, prevent disease and prolong life for the whole population through the organised efforts of society to provide an environment in which people can be healthy.

Three public health functions come together to work towards providing the conditions for healthy living ( Fig. 2 ). Health promotion enables people to take steps to maintain and improve their own health and wellbeing, including nutrition and physical activity. As well as supporting individual behaviour change, health promotion activities address social and environmental factors that affect individual health choices. Health protection approaches work to remove threats to health from the external environment, for example from infection, poisoning or injury, including falls and workplace injury. There is a also health services role for public health in developing, planning, implementing and evaluating the services needed by a population, including occupational health services.

What is public health?

Two further public health functions support the above roles. First, collection, interpretation and publication of data to monitor health trends and health needs and inform public health activities. Second, the formulation and evaluation of policies to create the conditions in which people can become healthy, addressing the determinants of health and health inequalities.

Current and future impact of musculoskeletal conditions on the health of the public

The impact of musculoskeletal conditions on the health of the public is substantial. In the United Kingdom, 10 million people live with long-term painful conditions of their joints, spine, bones or muscles . The UK Global Burden of Disease study identified musculoskeletal conditions as the largest single cause of years lived with disability (YLDs), and the third-largest cause of disability adjusted life years (DALYs) .

Improvements in health and health care mean that people in the United Kingdom are living longer than ever before. Musculoskeletal conditions are more common in older age. For example, among people aged 45-64 years, 4% of men and 7% of women have sought treatment from their GP for osteoarthritis of the hip, rising to 8% and 13% respectively among those aged 65-74 years .

This expected rise in prevalence of arthritis and musculoskeletal conditions is part of the wider trend in health where so-called non-communicable diseases account for an ever greater part of overall ill health. Rising levels of obesity and physical inactivity are major influences on this increase in non-communicable diseases, and musculoskeletal conditions are no exception. Meta-analyses suggest that obese people are more than twice as likely to develop osteoarthritis of the knee than those of normal body weight , with many studies calculating the risk as between four and six times greater . Risk increases with the level of obesity, such that a BMI of greater than 35 kg/m ² , compared to a BMI of 19 kg/m ² , could increase the odds of developing chronic knee pain by fourteen-fold . Physical inactivity at baseline was associated with long-term musculoskeletal conditions 11 years later in a large-scale Norwegian study . Although both of these risk factors are already the focus of sustained public health efforts, their implications for the musculoskeletal health of an ageing population are arguably underplayed in policy discussions.

The wider health impacts of musculoskeletal conditions

As well as causing pain and disability, musculoskeletal conditions affect general physical health. People with osteoarthritis have increased risk of cardiovascular disease and early mortality, an effect which appears to be partially reversed by joint replacement surgery, perhaps due to the restoration of normal activity levels . There is substantially increased mortality for older people following a fall and a broken hip . Rarer inflammatory musculoskeletal conditions such as rheumatoid arthritis can substantially shorten the lives of those affected .

Perhaps unsurprisingly musculoskeletal conditions have a huge impact on an individual’s mental health. This relationship is complex and reciprocal. Living with a painful musculoskeletal condition can lead to depression and anxiety. Depression is four times commoner for those people in persistent pain than in those without such pain . Almost a quarter of older people with osteoarthritis have depressed mood , while one in six people with rheumatoid arthritis has major depression . Moreover, when arthritic pain is at its worst, 68% of people report depressive symptoms . Conversely, psychological distress and depression worsen pain. A vicious cycle can therefore develop with ever worsening pain and low mood leading to social withdrawal, and a progressive reduction in quality of life. People with back pain and depression have greater disability than those with back pain alone . Depression in people with rheumatoid arthritis is linked with progressively worsening pain and overall disability .

Impact of musculoskeletal conditions on health and social care services

In the course of a year, a typical general practice is likely to see 21% of the registered population regarding a musculoskeletal problem . The majority of these consultations are due to back pain and osteoarthritis. The NHS in England spent £5.34 billion in 2012/13 on treating musculoskeletal conditions . This includes the cost of performing around 150,000 joint replacements yearly for people with severe osteoarthritis of the hip and knee. The cost of treating hip fractures is calculated separately, and costs the United Kingdom around £2 billion annually in clinical and social care costs . Musculoskeletal conditions are an important component of multimorbidity , frailty and depression . For people with multiple long-term conditions having a chronic painful musculoskeletal condition independently increases the risk of needing to be admitted for hospital care . Pain and disability is a substantial barrier to independent living. The need for long term social and residential care is often due to worsening musculoskeletal health.

Wider economic impact of musculoskeletal conditions

Poor musculoskeletal health is a major barrier to workplace participation. People with musculoskeletal disorders are less likely to be employed than people in good health, and more likely to retire early . If employed, people with musculoskeletal conditions are more likely to need time off and have reduced household income compared to those who do not . This lost productivity has an impact on the national economy, as well as affecting the state through lost revenue from taxation and increased need for state disability and low-income benefits. Over 30 million working days lost due to sickness absence caused by a musculoskeletal condition, second only to mental health problems . The costs of this, along with other indirect costs such as informal care and reduced productivity, are estimated at £14.8 billion for osteoarthritis and rheumatoid arthritis , with between £5.02 and £10.67 billion of employment-related costs attributable to back pain in the United Kingdom .

An ageing population, alongside rising levels of obesity and physical inactivity, will increase the number of people living with a painful musculoskeletal condition . Increasing numbers of people of working age will struggle to work due to these conditions, particularly with the projected rises in the age of retirement. More people than ever before will depend on health and social care services to manage their pain and disability. This economic pincer movement – lost productivity and increased costs – will place great demands on society.

Making musculoskeletal health a public health priority

The high prevalence of musculoskeletal conditions, the substantial consequences for those affected and the impact upon health and care services and wider society, means that a public health approach is required to make effective, lasting and meaningful improvements in the musculoskeletal health of the population. This was recognised in 2012 when Dame Sally Davies, the Chief Medical Officer for England, referred to the commonest musculoskeletal condition, osteoarthritis, as a “generally unrecognised public health priority” . The tools of public health can and should be used to create an environment where musculoskeletal health can flourish, where fewer people develop musculoskeletal conditions, and where those who do have a musculoskeletal condition are able to take steps to reduce the impact it has on their lives.