The need to address the burden of musculoskeletal conditions

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 . 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 . 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 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 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 and is currently undergoing a further revision. An atlas of musculoskeletal health in Europe is being developed in the EUMUSC.NET Project . In the USA an atlas has been produced of the burden of MSCs . 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 . 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 . Surveys have shown how best practice is not being delivered to many .

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 . 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 . Further data and downloadable figures are available at EUMUSC.NET .

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 considered a basic indicator for health but people experience deterioration in health due to many conditions. The majority of MSCs do not result in death, but the condition will contribute to limitations in activities and restricted participation with major consequences to individuals, families and carers and to society.

A methodology and standardisation is required for a summary measure that captures all aspects of a population’s health and not just mortality. There have been a number of attempts to derive summary health measures to place all conditions on a comparable scale across populations. Composite or summary health measures aim to reflect both the premature mortality and non-fatal health outcomes and in so doing aim to provide comparable measures of level of, and change in, the health of a population. The DALY is a commonly used summary measure, but to really grasp the full impact of these conditions further information is needed ( Table 1 ).

Table 1

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