Abstract
Musculoskeletal (MSK) conditions cause an enormous global burden, and this is dramatically increasing in developing countries, particularly due to rapidly ageing populations and increasing obesity. Many of the global non-communicable disease (NCD) initiatives need to expand beyond the traditional ‘top four’ NCD groups by incorporating MSK diseases. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. A better inclusion of MSK conditions will avoid doubling of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Other key opportunities for action include the following: ensuring the principles of ‘development effectiveness’ are met; strengthening leadership and commitment; building the research, information and evidence base; and reducing the incidence and disability of MSK conditions through better prevention. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.
Introduction
Musculoskeletal (MSK) conditions cause an enormous global burden . Of the 291 conditions included in the Global Burden of Disease (GBD) 2010 study, low back pain (LBP) ranked the highest in terms of disability and sixth in terms of overall burden, while neck pain (NP) ranked the fourth highest for disability and 21st for burden. Osteoarthritis (OA), rheumatoid arthritis (RA) and gout were also significant contributors to the global disability burden. The burden from MSK conditions will become an increasingly important issue for health systems as the number of people experiencing disabilities rises . This is particularly relevant in low- and middle-income countries (developing countries) due to rapidly ageing populations and increasing obesity, which are two of the major risk factors for MSK conditions .
While the evidence base has increased in developing countries over the recent years, there are still major gaps in our understanding of the prevalence of MSK conditions, and even less is known about the predictors, outcomes and potentially effective approaches to the primary, secondary and tertiary prevention of MSK conditions in this context. Various challenges in relation to reducing the burden of MSK in developing countries have been highlighted over the recent years. These include underfunded health care and related research ; insufficient number of health-care professionals trained to treat MSK conditions appropriately , and consequently inappropriate or delayed treatment when health care is available ; lack of understanding of the magnitude of the problem ; and lack of clinical guidelines suitable for developing countries . Additional challenges stem from barriers to accessing health care , especially among vulnerable populations such as low socio-economic groups and immigrants .
This chapter describes what is known about these issues and presents a multi-tiered approach to dealing with the growing burden from MSK problems in developing countries ( Fig. 1 ). This includes ensuring the principles of ‘development effectiveness’ are met; strengthening leadership and commitment; seeing the meaningful inclusion of MSK conditions in global and regional policy and programmes; building the research, information and evidence base, including the collection, analysis and use of quality data; reducing the incidence of MSK conditions through better prevention; and reducing disability from MSK conditions through better management. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.
Acknowledge the current and future problem
What we know now – the current burden from MSK conditions in developing countries
Burden of Disease (BoD) studies describe the burden arising from specific diseases, injuries or risk factors, using a summary measure called disability-adjusted life years (DALYs) . BoD research takes both fatal and non-fatal health outcomes into account, and it is thus a far more comprehensive measurement framework for assessing disease burden than simply relying on mortality or prevalence alone . DALYs are calculated by adding years of life lost in a population due to premature mortality (YLL) to healthy years of life lost in a population due to disability (YLD). The most recent BoD study, GBD 2010, was conducted over 5 years from 2007 to 2012 and involved collaboration between universities and experts in epidemiology and other areas of public health research from around the world. Disease burden was calculated for 291 causes in the 21 GBD world regions for the years 1990, 2005 and 2010 .
GBD 2010 revealed that 40% of the burden in developing countries is due to communicable diseases, 49% to non-communicable diseases (NCDs) and 11% to injuries. Table 1 shows the top 10 causes of burden from NCDs in developing countries. Three of the top 10 conditions in terms of both burden and disability were MSK conditions. Most notably, LBP caused the highest disability and the fourth highest burden of all the NCDs in the developing countries. In terms of broad cause groups, cardiovascular and circulatory diseases cause the greatest NCD burden in developing countries (214 million DALYs), followed by mental and behavioural disorders (141 million); cancers (130 million); MSK diseases (119 million); chronic respiratory diseases (101 million); diabetes and urogenital, blood and endocrine diseases (99 million); neurological disorders (57 million); digestive disorders (except cirrhosis) (27 million); and cirrhosis of the liver (25 million).
| Ranking | Burden | Disability | ||
|---|---|---|---|---|
| Disease | DALYs | Disease | YLDs | |
| 1 | Ischaemic heart disease | 85,540,200 | Low back pain | 58,417,100 |
| 2 | Stroke | 79,412,700 | Major depressive disorder | 50,177,100 |
| 3 | Chronic obstructive pulmonary disease | 65,607,700 | Neck pain | 24,044,800 |
| 4 | Low back pain | 58,417,100 | Chronic obstructive pulmonary disease | 24,274,600 |
| 5 | Major depressive disorder | 50,177,100 | Anxiety | 20,704,900 |
| 6 | Diabetes | 37,574,600 | Other musculoskeletal disorders | 19,159,300 |
| 7 | Cirrhosis | 24,622,700 | Migraine | 17,705,900 |
| 8 | Neck pain | 24,044,800 | Diabetes | 15,255,200 |
| 9 | Other musculoskeletal disorders | 21,112,300 | Other hearing loss | 12,842,200 |
| 10 | Anxiety | 20,704,900 | Drug use disorders | 12,425,700 |
MSK conditions were found to account for an enormous 19.2% of all disability (YLDs) in developing countries in 2010 and this increased from 16.8% in 1990. Again, this increase was largely due to population growth and ageing. In terms of broad cause groups, mental and behavioural disorders and MSK diseases cause by far the greatest NCD disability in developing countries (137 million and 116 million DALYs, respectively). This is followed by diabetes and urogenital, blood and endocrine diseases (42 million); chronic respiratory diseases (40 million); neurological disorders (32 million); cardiovascular and circulatory diseases (14 million); digestive disorders (except cirrhosis) (four million); cancers (two million); and cirrhosis of the liver (0.5 million).
It should be noted that some MSK conditions are classified under alternative categories in BoD. For example, carpal tunnel syndrome is classified under the neurological category, and injuries related to motor crashes and any fall-related MSK injury, fracture, sprain or strain (other than hip fracture) are classified under the injury category. This means that the full burden from MSKs is underestimated by GBD 2010. In addition, it is worth noting that in BoD research, the definition of disability is health loss resulting from episodes of disease and injury, often resulting in impairments of body structures and functions, as well as more complex human operations (e.g., mobility). Broader constructs of the magnitude of diseases such as participation restriction, well-being, carer burden, increased pressure on health-care systems and economic cost are not included. It is prudent to also consider these broader constructs when examining the impact of disease on populations. For MSK conditions, these are substantial. .
Of the 291 conditions studied in GBD 2010, LBP ranked 10th in developing countries in terms of burden and first in terms of disability. NP, OA, RA and other MSK conditions also ranked highly ( Table 2 ). As LBP, NP, OA and gout do not involve mortality, DALYs equate to YLDs for these conditions. LBP DALYs/YLDs were higher in males (32.3 million) than in females (26.1 million), with the raw number highest in the 35–45-year age group, and the age-standardised rate highest in the 75 + age group. DALYs/YLDs for NP were higher in females (13.3 million) compared with males (10.7 million); the raw number was also highest in the 35–45-year age group, although the age-standardised rate was highest in the 45–55-year age group. For OA, DALYs/YLDs were also higher in females (7.8 million) compared with males (4.6 million), with the raw number of DALYs/YLDs highest in the 50–60-year age group, and the rate highest in the 75 + age group. Gout was highest in males (36,000 DALYs/YLDs) compared with females (10,000 DALYs/YLDs); the raw number was also highest in the 50–60-year age group, and the age-standardised rate highest in the 75 + age group. Females also had higher DALYs and YLDs for RA in developing countries compared with males (2.1 million DALYs vs. 0.8 million, respectively; and 1.7 million YLDs vs. 0.4 million, respectively). For all MSK conditions, the raw number of DALYs was highest in the 50–60-year age group, and the rate highest in the 75 + age group, while the raw number of YLDs was highest in the 35–45-year age group, and the rate highest in the 75 + age group.
| MSK condition | DALYs | DALY ranking | YLDs | YLD ranking |
|---|---|---|---|---|
| Low back pain | 58,417,100 | 10 | 58,417,100 | 1 |
| Neck pain | 24,044,800 | 23 | 24,044,800 | 4 |
| Osteoarthritis | 12,421,100 | 41 | 12,421,100 | 13 |
| Rheumatoid arthritis | 2,956,280 | 93 | 2,119,610 | 58 |
| Gout | 46,313 | 174 | 46,313 | 144 |
| Other musculoskeletal | 21,112,300 | 25 | 19,159,300 | 7 |
What will happen – the future burden from MSK conditions in developing countries
From 1990 to 2010, the burden in developing countries attributable to MSK conditions increased 60% ( Table 3 ). This increase in DALYs was relatively consistent across MSK conditions, and was due to population growth and ageing . A cause for great concern is that population growth, ageing and other risk factors for the burden of MSK conditions will increase dramatically in developing countries over the coming decades.
| 1990 | 2010 | % Increase | |
|---|---|---|---|
| Musculoskeletal diseases | 74,445,200 | 118,998,000 | 60% |
| Low back pain | 37,243,900 | 58,417,100 | 57% |
| Neck pain | 15,692,400 | 24,044,800 | 53% |
| Osteoarthritis | 6,875,780 | 12,421,100 | 81% |
| Rheumatoid arthritis | 1,831,450 | 2,956,280 | 61% |
| Gout | 26,973 | 46,313 | 72% |
| Other musculoskeletal | 12,774,700 | 21,112,300 | 65% |
Age is one of the most common risk factors for MSKs , and the greatest effects of population ageing are predicted in developing countries . By 2050, it is predicted there will be five times as many people over 40 years living in these countries compared to wealthier countries, with an estimated 3.53 billion people 40 years or older in developing countries compared to 645 million people in high-income countries . In most of the developed world, demographic change occurred gradually, following steady socio-economic growth over several decades . However, in many developing countries, this change is being compressed into two or three decades, and health systems and national economies are ill-equipped to deal with this.
Many of the risk factors associated with MSKs in high-income countries are currently present in developing countries, including obesity, increased motorisation and work-related issues . Obesity is expected to rise dramatically in the developing world over the coming two decades . Increased levels of motorisation are resulting in larger numbers of motor accidents , escalating the incidence of whiplash-associated disorders and other motor vehicular-related trauma. An estimated 80–90% of the population in developing countries are involved in ‘heavy work’ ; work demands are extensive in subsistence communities; and activities such as the collection of water and farming have been shown to increase the risk of LBP . In urban areas, there is rapid industrial growth and the prevalence of occupational MSK conditions is already very common . As a consequence of these factors, the number of people experiencing MSKs in developing countries will increase dramatically over the coming decades, and this will result in an exponential increase in the burden from MSKs in these countries.
The impact from the increasing MSK burden in developing countries is likely to be extreme. Health promotion and treatment services do not receive the resourcing seen in high-income countries, and health insurance and social security frequently do not exist. Further to this, a large proportion of those affected are in the most productive years of life when functioning is often a necessity to support both younger and older family members.
The findings from GBD 2010 have major implications regarding health system investment decisions. Due to the current and future epidemiological pattern and associated costs of MSK conditions, health systems need to develop coherent policies for dealing with this burden . Extending retirement age is a proposed strategy to deal with the resource burden of the ageing global population; however, the substantial MSK burden in this ageing population will markedly diminish the capacity to implement this strategy successfully . Further, many health systems are already struggling with the challenges resulting from the epidemiological transition and the consequent burden from NCDs. Health system investments will support future decades, and, thus, in addition to health human resources and training, they need to reflect future burden. The pace of the demographic and epidemiological change in developing countries is such that a forward-looking assessment of future disease burden is critical, while research to assess the most effective and affordable strategies for preventing and managing the burden from MSKs is urgently needed.
Acknowledge the current and future problem
What we know now – the current burden from MSK conditions in developing countries
Burden of Disease (BoD) studies describe the burden arising from specific diseases, injuries or risk factors, using a summary measure called disability-adjusted life years (DALYs) . BoD research takes both fatal and non-fatal health outcomes into account, and it is thus a far more comprehensive measurement framework for assessing disease burden than simply relying on mortality or prevalence alone . DALYs are calculated by adding years of life lost in a population due to premature mortality (YLL) to healthy years of life lost in a population due to disability (YLD). The most recent BoD study, GBD 2010, was conducted over 5 years from 2007 to 2012 and involved collaboration between universities and experts in epidemiology and other areas of public health research from around the world. Disease burden was calculated for 291 causes in the 21 GBD world regions for the years 1990, 2005 and 2010 .
GBD 2010 revealed that 40% of the burden in developing countries is due to communicable diseases, 49% to non-communicable diseases (NCDs) and 11% to injuries. Table 1 shows the top 10 causes of burden from NCDs in developing countries. Three of the top 10 conditions in terms of both burden and disability were MSK conditions. Most notably, LBP caused the highest disability and the fourth highest burden of all the NCDs in the developing countries. In terms of broad cause groups, cardiovascular and circulatory diseases cause the greatest NCD burden in developing countries (214 million DALYs), followed by mental and behavioural disorders (141 million); cancers (130 million); MSK diseases (119 million); chronic respiratory diseases (101 million); diabetes and urogenital, blood and endocrine diseases (99 million); neurological disorders (57 million); digestive disorders (except cirrhosis) (27 million); and cirrhosis of the liver (25 million).
| Ranking | Burden | Disability | ||
|---|---|---|---|---|
| Disease | DALYs | Disease | YLDs | |
| 1 | Ischaemic heart disease | 85,540,200 | Low back pain | 58,417,100 |
| 2 | Stroke | 79,412,700 | Major depressive disorder | 50,177,100 |
| 3 | Chronic obstructive pulmonary disease | 65,607,700 | Neck pain | 24,044,800 |
| 4 | Low back pain | 58,417,100 | Chronic obstructive pulmonary disease | 24,274,600 |
| 5 | Major depressive disorder | 50,177,100 | Anxiety | 20,704,900 |
| 6 | Diabetes | 37,574,600 | Other musculoskeletal disorders | 19,159,300 |
| 7 | Cirrhosis | 24,622,700 | Migraine | 17,705,900 |
| 8 | Neck pain | 24,044,800 | Diabetes | 15,255,200 |
| 9 | Other musculoskeletal disorders | 21,112,300 | Other hearing loss | 12,842,200 |
| 10 | Anxiety | 20,704,900 | Drug use disorders | 12,425,700 |
MSK conditions were found to account for an enormous 19.2% of all disability (YLDs) in developing countries in 2010 and this increased from 16.8% in 1990. Again, this increase was largely due to population growth and ageing. In terms of broad cause groups, mental and behavioural disorders and MSK diseases cause by far the greatest NCD disability in developing countries (137 million and 116 million DALYs, respectively). This is followed by diabetes and urogenital, blood and endocrine diseases (42 million); chronic respiratory diseases (40 million); neurological disorders (32 million); cardiovascular and circulatory diseases (14 million); digestive disorders (except cirrhosis) (four million); cancers (two million); and cirrhosis of the liver (0.5 million).
It should be noted that some MSK conditions are classified under alternative categories in BoD. For example, carpal tunnel syndrome is classified under the neurological category, and injuries related to motor crashes and any fall-related MSK injury, fracture, sprain or strain (other than hip fracture) are classified under the injury category. This means that the full burden from MSKs is underestimated by GBD 2010. In addition, it is worth noting that in BoD research, the definition of disability is health loss resulting from episodes of disease and injury, often resulting in impairments of body structures and functions, as well as more complex human operations (e.g., mobility). Broader constructs of the magnitude of diseases such as participation restriction, well-being, carer burden, increased pressure on health-care systems and economic cost are not included. It is prudent to also consider these broader constructs when examining the impact of disease on populations. For MSK conditions, these are substantial. .
Of the 291 conditions studied in GBD 2010, LBP ranked 10th in developing countries in terms of burden and first in terms of disability. NP, OA, RA and other MSK conditions also ranked highly ( Table 2 ). As LBP, NP, OA and gout do not involve mortality, DALYs equate to YLDs for these conditions. LBP DALYs/YLDs were higher in males (32.3 million) than in females (26.1 million), with the raw number highest in the 35–45-year age group, and the age-standardised rate highest in the 75 + age group. DALYs/YLDs for NP were higher in females (13.3 million) compared with males (10.7 million); the raw number was also highest in the 35–45-year age group, although the age-standardised rate was highest in the 45–55-year age group. For OA, DALYs/YLDs were also higher in females (7.8 million) compared with males (4.6 million), with the raw number of DALYs/YLDs highest in the 50–60-year age group, and the rate highest in the 75 + age group. Gout was highest in males (36,000 DALYs/YLDs) compared with females (10,000 DALYs/YLDs); the raw number was also highest in the 50–60-year age group, and the age-standardised rate highest in the 75 + age group. Females also had higher DALYs and YLDs for RA in developing countries compared with males (2.1 million DALYs vs. 0.8 million, respectively; and 1.7 million YLDs vs. 0.4 million, respectively). For all MSK conditions, the raw number of DALYs was highest in the 50–60-year age group, and the rate highest in the 75 + age group, while the raw number of YLDs was highest in the 35–45-year age group, and the rate highest in the 75 + age group.
| MSK condition | DALYs | DALY ranking | YLDs | YLD ranking |
|---|---|---|---|---|
| Low back pain | 58,417,100 | 10 | 58,417,100 | 1 |
| Neck pain | 24,044,800 | 23 | 24,044,800 | 4 |
| Osteoarthritis | 12,421,100 | 41 | 12,421,100 | 13 |
| Rheumatoid arthritis | 2,956,280 | 93 | 2,119,610 | 58 |
| Gout | 46,313 | 174 | 46,313 | 144 |
| Other musculoskeletal | 21,112,300 | 25 | 19,159,300 | 7 |
What will happen – the future burden from MSK conditions in developing countries
From 1990 to 2010, the burden in developing countries attributable to MSK conditions increased 60% ( Table 3 ). This increase in DALYs was relatively consistent across MSK conditions, and was due to population growth and ageing . A cause for great concern is that population growth, ageing and other risk factors for the burden of MSK conditions will increase dramatically in developing countries over the coming decades.
| 1990 | 2010 | % Increase | |
|---|---|---|---|
| Musculoskeletal diseases | 74,445,200 | 118,998,000 | 60% |
| Low back pain | 37,243,900 | 58,417,100 | 57% |
| Neck pain | 15,692,400 | 24,044,800 | 53% |
| Osteoarthritis | 6,875,780 | 12,421,100 | 81% |
| Rheumatoid arthritis | 1,831,450 | 2,956,280 | 61% |
| Gout | 26,973 | 46,313 | 72% |
| Other musculoskeletal | 12,774,700 | 21,112,300 | 65% |
Age is one of the most common risk factors for MSKs , and the greatest effects of population ageing are predicted in developing countries . By 2050, it is predicted there will be five times as many people over 40 years living in these countries compared to wealthier countries, with an estimated 3.53 billion people 40 years or older in developing countries compared to 645 million people in high-income countries . In most of the developed world, demographic change occurred gradually, following steady socio-economic growth over several decades . However, in many developing countries, this change is being compressed into two or three decades, and health systems and national economies are ill-equipped to deal with this.
Many of the risk factors associated with MSKs in high-income countries are currently present in developing countries, including obesity, increased motorisation and work-related issues . Obesity is expected to rise dramatically in the developing world over the coming two decades . Increased levels of motorisation are resulting in larger numbers of motor accidents , escalating the incidence of whiplash-associated disorders and other motor vehicular-related trauma. An estimated 80–90% of the population in developing countries are involved in ‘heavy work’ ; work demands are extensive in subsistence communities; and activities such as the collection of water and farming have been shown to increase the risk of LBP . In urban areas, there is rapid industrial growth and the prevalence of occupational MSK conditions is already very common . As a consequence of these factors, the number of people experiencing MSKs in developing countries will increase dramatically over the coming decades, and this will result in an exponential increase in the burden from MSKs in these countries.
The impact from the increasing MSK burden in developing countries is likely to be extreme. Health promotion and treatment services do not receive the resourcing seen in high-income countries, and health insurance and social security frequently do not exist. Further to this, a large proportion of those affected are in the most productive years of life when functioning is often a necessity to support both younger and older family members.
The findings from GBD 2010 have major implications regarding health system investment decisions. Due to the current and future epidemiological pattern and associated costs of MSK conditions, health systems need to develop coherent policies for dealing with this burden . Extending retirement age is a proposed strategy to deal with the resource burden of the ageing global population; however, the substantial MSK burden in this ageing population will markedly diminish the capacity to implement this strategy successfully . Further, many health systems are already struggling with the challenges resulting from the epidemiological transition and the consequent burden from NCDs. Health system investments will support future decades, and, thus, in addition to health human resources and training, they need to reflect future burden. The pace of the demographic and epidemiological change in developing countries is such that a forward-looking assessment of future disease burden is critical, while research to assess the most effective and affordable strategies for preventing and managing the burden from MSKs is urgently needed.
Related posts:
Musculoskeletal health, frailty and functional decline
Determinants of MSK health and disability – Social determinants of inequities in MSK health
Determinants of MSK health and disability: Lifestyle determinants of symptomatic osteoarthritis
Corrigendum to “Granulomatous inflammation: the overlap of immune deficiency and inflammation” [Best Pract Res Clin Rheumatol 28 (2014) 191–212]
‘Erratum to “Osteoporosis and fragility fractures: Vertebral fractures” [Best Practice & Research Clinical Rheumatology 27 (2013) 743–55]’
A public health approach to musculoskeletal health
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
