Best Practice & Research Clinical Rheumatology 28 (2014) 517e532

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A public health approach to musculoskeletal health P.M. Clark, BA, MA, Public Health Registrar a, B.M. Ellis, BA, MBBS, MSc, MPH, MRCP, Senior Clinical Policy Adviser b, * a b

London and KSS School of Public Health, London, UK Arthritis Research UK, London, UK

a b s t r a c t Keywords: Musculoskeletal pain Arthritis Public health Prevention Obesity Exercise

An ageing, physically inactive and increasingly obese population, coupled with finite health and social care resources, requires a shift from treating musculoskeletal disease when it arises to a preventive approach promoting lifelong musculoskeletal health. A public health approach to musculoskeletal health ensures that people are able to live not only long, but also well. Supporting selfmanagement, addressing common misconceptions about the inevitability of musculoskeletal conditions, and offering brief interventions to support necessary lifestyle changes are basic public health functions that all health professionals can deliver. More specialist public health skills including needs assessment, data interpretation and service planning are also needed to deliver high quality services. These will require improvements in the data collected about musculoskeletal health nationally. A public health approach would benefit individuals through reduced pain and improved function due to musculoskeletal conditions, and wider society by minimising lost economic productivity and lowering health and social care costs. © 2014 Published by Elsevier Ltd.

* Corresponding author. Tel.: þ44 20 7307 2217. E-mail addresses: [email protected] (P.M. Clark), [email protected] (B.M. Ellis). 1521-6942/© 2014 Published by Elsevier Ltd.


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Introduction In 2013 Arthritis Research UK convened a round table discussion to explore the opportunities in using a public health approach to improve population musculoskeletal health. The impetus for this meeting was the reorganisation of the public health system in England. This included the creation of Public Health England, which had begun a review of national strategic priorities for public health. The meeting included senior academic researchers; representatives from public health organisations e Public Health England, the Faculty of Public Health, the Royal Society of Public Health; patient organisations e Age UK, the Arthritis and Musculoskeletal Alliance, Arthritis Care, the National Osteoporosis Society; and health professional organisations e the British Orthopaedic Association, the British Society for Rheumatology, the Chartered Society of Physiotherapy, the Primary Care Rheumatology Society, and the Royal College of General Practitioners. In the months following this meeting, Arthritis Research UK produced a publication, Musculoskeletal health e a public health approach [1]. This article is based on that report and has three sections. The first section reviews the concepts of musculoskeletal health, musculoskeletal conditions and the role for public health in addressing these. Section two considers why a public health approach to musculoskeletal conditions is desirable and achievable. The final section outlines the major components required to achieve such an approach. Section 1: Musculoskeletal health, musculoskeletal conditions, and public health 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. Musculoskeletal conditions Broadly, three groups of musculoskeletal conditions can affect people leading to poor musculoskeletal health [2]. The commonest group comprises conditions of musculoskeletal pain such as

Fig. 1. Factors comprising musculoskeletal health [1].

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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 [3] and vitamin D levels [4], 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 [5,6]. 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. 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. Section 2: The case for a public health approach 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 [7]. 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) [8]. 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 [9]. 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 noncommunicable 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 [10], with many studies calculating the risk as between four and six times greater [11e13]. Risk increases with the level of obesity, such that a BMI of greater than 35 kg/m2, compared to a BMI of 19 kg/m2, could increase the odds of developing chronic knee pain by fourteen-fold [14]. Physical inactivity at baseline was associated with long-term musculoskeletal conditions 11 years later in a large-scale Norwegian study [15]. 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.

Stage of life

Risk factors

Maternal health Low birth weight

Maternal smoking Childhood and adolescence


Opportunities C Tackle maternal smoking C Promote appropriate physical activity pregnancy C Low pre-conception BMI strength C Promote adequate nutrition (e.g. Vitamin D) C Tackle maternal smoking strength C Screening for developmental dysplasia C Promote healthy childhood nutrition

Osteoarthritis Back pain


Rheumatoid arthritis Musculoskeletal pain Back pain Musculoskeletal pain Osteoarthritis Back pain Gout Musculoskeletal pain Osteoarthritis Osteoporosis Increased falls risk Osteoporosis Musculoskeletal pain Osteoarthritis Back pain Gout Increased falls risk Osteoporosis Musculoskeletal pain

Poor nutrition Obesity

Physical inactivity

© Arthritis Research UK, 2014



Musculoskeletal Injury

Physical inactivity

Examples of interventions


Hip dysplasia Poor early childhood growth and adolescent eating disorders Obesity Musculoskeletal pain Osteoarthritis Back pain Physical inactivity Osteoporosis


Older Life

Associated Osteoporosis Reduced muscle Osteoporosis Reduced muscle Osteoporosis Reduced muscle Osteoporosis Reduced muscle Osteoarthritis Osteoporosis

C Reduce obesity

C Exercise to promote greater bone density and muscle C Take Life On (Scottish Government) strength in later life C Modify high-risk environments in sports and C FIFA 11þ C Workplace interventions (exercise workplaces therapy, workplace adaptations etc.) C Early access to high quality treatment after injury C Lifestyle changes

C Supported weight loss programmes C Smokefree (NHS)

C Physical activity guidelines and health C Improve overall musculoskeletal health promotion in the workplace C High impact physical activity to promote strengthening of the bones C Maintain healthy nutrition and body weight C Vitamin D supplementation

C Increase physical activity to strengthen bones, mus- C Implementing national physical activity guidelines (2011) for the over 65s cles and joints and improve balance and co-ordination C Remove barriers that prevent older people engaging inactivity (inaccessible, lack of transport, social fears)

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High level of vigorous activity during pregnancy Maternal nutrition


Table 1 Avoidable threats to musculoskeletal health through the lifecourse.

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Fig. 2. What is public health? [1].

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 [16] and early mortality, an effect which appears to be partially reversed by joint replacement surgery, perhaps due to the restoration of normal activity levels [17]. There is substantially increased mortality for older people following a fall and a broken hip [18]. Rarer inflammatory musculoskeletal conditions such as rheumatoid arthritis can substantially shorten the lives of those affected [19]. 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 [20]. Almost a quarter of older people with osteoarthritis have depressed mood [21,22], while one in six people with rheumatoid arthritis has major depression [23]. Moreover, when arthritic pain is at its worst, 68% of people report depressive symptoms [24]. 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 [25]. Depression in people with rheumatoid arthritis is linked with progressively worsening pain and overall disability [26]. 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 [27]. 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 [28]. 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 [29]. Musculoskeletal conditions are an important component of multimorbidity [30], frailty [31] and depression [32]. 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 [33]. 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 [34]. If employed, people with musculoskeletal conditions are more likely to need time off and have reduced household income compared to those who do not [35]. 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 [36].


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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 [37], with between £5.02 and £10.67 billion of employment-related costs attributable to back pain in the United Kingdom [38]. An ageing population, alongside rising levels of obesity and physical inactivity, will increase the number of people living with a painful musculoskeletal condition [6]. 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 e lost productivity and increased costs e 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” [39]. 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. Section 3: Implementing a comprehensive public health approach Current approaches to musculoskeletal health primarily focus on dealing with problems as they arise. This includes the provision of medical care to alleviate symptoms and social care to support daily living. The high prevalence of musculoskeletal conditions and the modifiable risk factors summarised above point towards the use of a public health approach to musculoskeletal health. Even relatively small reductions in the prevalence of major risk factors across a whole population will result in substantial improvements in musculoskeletal health, reducing costs and burden on individuals, health and care services, the economy and wider society. A comprehensive public health approach to musculoskeletal health requires specific as well as generic components (Fig. 3). Population health needs assessments (such as the Joint Strategic Needs Assessment, or Annual Public Health Reports in England), are informed by calculating the prevalence and impact of different specific conditions, and should always include musculoskeletal conditions. Much of the public health approach to non-communicable diseases is generic, because of the common risk factors, for example, addressing physical inactivity or obesity. Some groups, including those with musculoskeletal conditions, may require specific targeting of health promotion activities or public health interventions either because they have increased risk or because messages may need to be tailored to their needs. When designing services to meet the needs of people with musculoskeletal

Fig. 3. Condition specific and generic components to a public health approach [1].

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conditions, health services are generally condition-specific, whereas social care services are usually generic across conditions. Outcome measures for individual and population health should be both generic and specific to ensure that while the health of the population overall is being improved, vulnerable groups are not excluded. A condition-specific public health approach to musculoskeletal health includes five major themes. First, identifying and reducing risk factors for specific musculoskeletal conditions at population level with specific reference to musculoskeletal health. Second, enabling people to take steps to manage and improve their own musculoskeletal health by addressing inaccurate health beliefs about musculoskeletal conditions among those living with these conditions and supporting self management. Third, implementing a public health approach to health and care services, ensuring timely and equitable access to services and promoting and supporting self-management among people living with a musculoskeletal condition. Fourth, an approach to the workplace that recognises its important influence on musculoskeletal health, both as a cause of musculoskeletal conditions and also as an opportunity to promote musculoskeletal health. Finally, high quality data about musculoskeletal health is needed to support needs assessment, service evaluation and to target interventions where they are most needed. Tackling risk factors for developing musculoskeletal conditions Many risk factors such as obesity and physical inactivity are already the subject of health promotion activities. Often the rationale for these has been framed in terms of the prevention of diabetes or cardiovascular disease. Explicit consideration of musculoskeletal health should be built into these public health programmes for three reasons. First, when modelling and measuring the benefits of such programmes, specifically including the expected musculoskeletal health gain will improve the quality of any evaluation. Second, prevalent health beliefs mean that many people with musculoskeletal conditions are unaware of the benefits they may derive from modifying their own risk factors. Explicit discussion of these benefits may improve the attractiveness of lifestyle change because of its salience, and also enable a discussion to address issues about pain as a potential barrier to physical activity. Finally, for some people who do not have a specific musculoskeletal condition, the opportunity of improved musculoskeletal health may be a particular incentive for changing some aspects of their lifestyle, particularly increasing physical activity. The connection between physical activity and musculoskeletal health may seem fairly intuitive for many people, where the benefits e such as reduced risk of pain and disability e are relatively tangible compared with, for instance, reducing one’s risk of developing diabetes or cardiovascular problems. Few are aware that being overweight and physically inactive at every stage of life substantially increases their risk of joint or back pain and physical disability in the future. This is in spite of widespread recognition of the implications of those risk factors for diabetes, heart disease and other long-term conditions. The opportunities to modify risk factors for specific musculoskeletal conditions should be embedded as early as possible in the life course. Physical activity in early life is particularly important because it promotes healthy development of the adult skeleton. For example, bone strength is one of the most important factors in determining whether a minor injury, such as a fall from a standing height, will lead to a fragility fracture. Over 90% of adult bone mass is accumulated during childhood and adolescence [40], and bones typically reach peak mineral density and strength around age 30 years before beginning to decline predictably after age 50 years (Fig. 4) [41]. The positive effect of physical activity on bone development in childhood and adolescence can reduce fracture risk much later in life. Changing health beliefs and supporting self-management Common, but incorrect, health beliefs can prevent those with musculoskeletal conditions from taking active steps to improve their own health. For example, a common mistaken view is that persistently painful joints and backs require rest [42]. Many people with musculoskeletal conditions wrongly accept that ‘nothing can be done’ to improve their health [43] and do not realise the


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Fig. 4. Graph showing changes in bone density with rising age [1].

extent to which weight loss and appropriate physical activity could reduce their pain and improve their quality of life [44]. If these heath beliefs are not addressed, people with musculoskeletal pain will not be receptive to general public health messages about increasing physical activity. To be effective, such messages must be targeted towards people with musculoskeletal pain and explicitly challenge beliefs that nothing can be done, and that painful musculoskeletal conditions require rest. Correct diagnosis with appropriate advice and support from health professionals is important for people living with musculoskeletal conditions [45]. Yet, for some people with conditions of musculoskeletal pain, excessive focus on medical solutions can result in an unrewarding cycle of investigations to identify the cause of the pain and a fruitless search for a ‘cure’. Such over-medicalisation discourages people in pain from taking simple steps to improve their own health through lifestyle change [46]. Media campaigns aimed at informing the general population about back pain have in some circumstances changed public beliefs about the need for medical investigation of back pain and the benefits of physical activity [47]. Population health beliefs should be addressed because they are a major predictor of health outcomes for people with musculoskeletal conditions [48,49]. In particular, people who mistakenly fear that physical activity or work will worsen their problem are at increased risk of long-term pain and disability, as are those with so-called “catastrophising” beliefs who tend to focus on the worst possible outcomes of their pain [50]. Using psychological therapies to address these beliefs has the potential to reduce chronicity and associated pain and disability [51].

Implementing a public health approach to health and care services A public health approach is needed towards musculoskeletal health and care services. This includes making an accurate assessment of current and predicted burden of musculoskeletal ill health and any inequalities and adverse trends, so that appropriate services can be commissioned. A public health approach can also be used to design and improve services, embedding four public health principles to improve population outcomes: early diagnosis, improved access to services, use of risk stratification tools to improve clinical pathways, and encouraging those delivering services to engage in health promotion activities. Early identification and diagnosis and treatment of musculoskeletal conditions, with high quality support from appropriate professionals, can prevent long-term pain and disability. Rheumatoid arthritis rapidly causes irreversible joint damage, but few people who develop this condition receive the urgent, intensive care that could prevent long-term pain and disability, and reduce NHS and societal costs [52]. In the case of injuries, early intervention and rehabilitation can prevent recurrent injury leading to cumulative and permanent damage [53]. Because untreated pain can become persistent, due to changes in pain pathways in the nervous system, early intervention can reduce chronicity and disability [54]. Fracture liaison services are an example of a highly cost effective way of preventing fragility fractures [55]. Older people at high risk of fractures, particularly those with previous fragility fractures, take part in a multidisciplinary assessment and a plan e including medication, home adaptation, self-care and lifestyle advice e is agreed to reduce their risk.

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A number of models have been proposed to enhance access to services for people with musculoskeletal pain and there is a role for public health in evaluating and promoting these. In Scotland, NHS24 provides telephone triage directing people to appropriate services such as physiotherapy, without the need to first make an appointment with a GP. In some areas of the United Kingdom, people with an episode of musculoskeletal pain can directly self-refer to NHS physiotherapy services. Widespread and equitable public access to physical activity programmes could make health centres the first place where people with musculoskeletal pain would go to manage their condition. This will require health centre staff who are informed about musculoskeletal conditions and skilled in supporting people in pain to engage in appropriate physical activity. Where large numbers of people seek health care each year, as is the case for back pain, a public health approach should include designing systems of care so different populations receive the best treatment appropriate for them. STarTBack is an evidence-based example of this approach [56]. This clinical questionnaire allows three distinct populations of people with back pain to be identified, each of which can then receive appropriate care. Systems of care that routinely use STarTBack improve population musculoskeletal health outcomes and reduce overall cost [57]. Health and social care professionals, including clinical staff, can deliver public health messages about lifestyle change to people with musculoskeletal conditions when providing care. The aim should be to empower people with musculoskeletal pain to take steps to improve their own health, to promote self-management and to avoid over-medicalisation. Doctors, nurses and physiotherapists are uniquely placed to promote public health messages, delivering succinct advice or using brief interventions about weight loss or appropriate physical activity. Structured self-management education programmes are another approach to supporting people, and aim to improve their health by tackling health beliefs and improving self-efficacy. These are led by health professionals, health trainers or other people with long-term conditions. They can be delivered in a group or individual setting, or as self-directed e-learning. Advocates point to some studies that suggest such programmes improve people’s symptoms and quality of life and their self-confidence to manage their symptoms without using health services [58]. Although a recent Cochrane review was equivocal about these benefits, concluding that they only slightly improved self-management skills, pain and function for patients with osteoarthritis [59], more targeted approaches may be more effective. For example, a small scale self-management programme focussed specifically on pain management, reduced health care use and as a consequence reduced costs [60]. Telephone-delivered cognitive behavioural therapy for patients with fibromyalgia delivered short and medium-term improvements in self-reported health outcomes [61]. Clinicians may require training to acquire the knowledge, skills and attitudes to support lifestyle change in their patients. Specific resources may be helpful here, such as a nationally-agreed guidelines to recommended levels of physical activity for people of different ages [62], and types of physical activity for those with different musculoskeletal conditions [63]. System incentives and resources should be aligned to ensure that appropriate physical activity facilities and services are available and accessible for people to use. This should include equity of access so that non-drug approaches of proven benefit, such as physical activity or weight management, are assessed and made available within health systems as pharmacological treatments. Many health systems such as the NHS in England [64] now provide regular health checks for their populations to screen people for avoidable risk factors and reduce risk of ill health. Frequently, this includes advising people to increase their physical activity levels. Musculoskeletal conditions are very common, and unless explicitly addressed can be a barrier to physical activity. Two or three simple screening questions [65] could identify people with a musculoskeletal problem, allowing targeted physical activity and the reassurance that physical activity is safe and beneficial for their condition. Addressing musculoskeletal health in the workplace For most people work can benefit health in two ways. First, undertaking meaningful work is an important part of an individual's sense of health and wellbeing [66]. Second, workplaces provide an opportunity to benefit health in general and musculoskeletal health specifically. This includes


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preventing injury as well as enabling and encouraging appropriate physical activity and addressing obesity. Certain types of work and workplace conditions may have a negative impact on musculoskeletal health, failing to create a healthy environment and increasing the risk of musculoskeletal conditions. For example, jobs that require frequent bending and twisting can predispose to back pain, heavy lifting has been associated with back pain and osteoarthritis of the knees, and upper limb disorders such as carpal tunnel syndrome may be associated with some types of manual work [67]. Physical activities associated with a job only partly explain the varying prevalence of musculoskeletal problems at work. Cultural issues and psychological factors are an important component of musculoskeletal health at work in ways that are only partially understood [68]. Work-related pain disorders can be more strongly associated with perceived workplace stress and high job demands than they are with the physical characteristics of any particular job [69]. Much can be done to reduce any threats to musculoskeletal health from the workplace. Modifying physical environments and work practices reduces incidence of acute injury. Early intervention to identify and address problems and the underlying occupational exposure can prevent chronic pain, disability and work loss [70]. A number of workplace interventions have been tried including exercise therapy, behavioural change techniques, workplace adaptations and provision of additional services. A study assessing the cost-effectiveness of such interventions estimated that they had the potential to return at least an additional 3% of employees to work and cost less than an additional £3000 per employee [71]. As well as the causal relationships described above, the workplace provides a unique opportunity for health promotion. High costs to both private and state employers of lost work due to musculoskeletal ill health may provide particular incentives to promote physical activity and healthy nutrition in the workplace, for example through implementing the relevant NICE (National Institute for Health and Care Excellence) guidance [72]. For employees, availability of healthy food at work, employment packages including support for physical activity facilities and active travel (such as walking and cycling), and early access to high quality occupational health services when required all help to maintain musculoskeletal health and prevent associated lost work [73]. Good occupational health services will identify and enable people with musculoskeletal conditions to recover their health and remain engaged with work [74]; and support people who have been out of work due to a musculoskeletal condition to make a successful return to meaningful work [75]. Occupational health services could play a leading role in musculoskeletal health promotion, using the workplace to tackle risk factors such as physical inactivity and obesity.

Better data about musculoskeletal health The collection, interpretation and publication of data is an essential public health function that informs all other public health activity. The commissioning cycle has three parts, each informed by data (Fig. 5). First, in order to design public health, clinical and social services and programmes, robust information is required about the health of the population. Next, once services are running, data are required to understand what activity is being performed by those services e and at what cost e and who in the population is using them. Finally, the quality and value of services should be determined through the routine monitoring of health outcomes delivered by the service. This in turn will affect the health of the population and so the cycle repeats. For musculoskeletal health, it is difficult to obtain data on population need, health service activity and health outcomes, risking a loss of public health focus on this topic. Partly, this is because of historic attention to mortality as the priority of health improvement and health service activity [39]. This is reflected in health policies, which have tended to address the major killers such as cardiovascular disease and cancer. There has been less attention to conditions which mainly reduce quality of life, such as most musculoskeletal conditions. High quality data are needed to help allocate appropriate resources towards tackling poor musculoskeletal health and addressing inequalities. Intelligence about patterns of ill health should guide design and location of services. Information about musculoskeletal health trends in the

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Fig. 5. Types of data needed for musculoskeletal health intelligence [1].

population and changes in response to interventions can guide quality improvement in specific services and enable identification of successful programmes, supporting their spread and wider implementation.

Assessing population health need Health intelligence for public health purposes can come from a number of sources, including national and local surveys. For example, a number of local authorities currently use surveys to assess local population musculoskeletal health need [76], but there is no standard approach to the methodology or questions used. Nationally, publicly funded health surveys such as the Health Survey for England and General Lifestyle Survey include questions about pain, mobility or general musculoskeletal health. The content of these has varied between the four United Kingdom nations and are not always designed and included in a systematic way to maximise the benefit of those questions. For example, in any given year questions about musculoskeletal health should be linked to questions about health impact, as well as major risk factors such as physical inactivity and obesity. At European level, the group has developed a set of Health Care Quality Indicators for osteoarthritis and rheumatoid arthritis which can be used to monitor the structures, processes and outcomes of health care for musculoskeletal conditions in Europe. This indicator set could provide the basis for international standards for musculoskeletal health outcomes [82]. To address the lack of local data within the United Kingdom, Arthritis Research UK is developing the ‘Musculoskeletal Calculator’, due to launch in 2014, that uses statistical modelling to produce robust estimates of prevalence of four musculoskeletal conditions of public health importance e osteoarthritis of the hip and knee, back pain, rheumatoid arthritis, and fragility fracture risk. This tool will enable local government, public health departments and commissioners of health and care services more accurately determine levels of need in their populations and plan services and interventions accordingly [77].


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Data about clinical activity Musculoskeletal health care is often delivered in multiple settings by different health professionals providing different treatments. As a consequence, clinical activity data, including information about diagnosis and treatment, are sparse. In England, for example, current routine NHS data collections centre on secondary care through Hospital Episode Statistics (HES). HES provides good data on specific relevant episodes of inpatient care (such as joint replacement surgery, or treatment for major fractures such as broken hips). However, HES outpatient datasets usually only capture the attendance, without including any diagnosis or treatment information. Similarly, there is minimal information collected about community care. National registries provide an important source of data to inform and protect public health, supplementing whatever data there are from routine collection. The British Society for Rheumatology Biologics Register collects patient safety data on a sample of people receiving relatively new biologic treatments, where long-term effects are still unknown [83]. Since 2002 the National Joint Registry has collected information on all hip, knee, ankle, elbow and shoulder replacement operations in England, Wales and Northern Ireland and monitored the performance of joint replacement implants. Such monitoring enables national trends to be better identified, for example in 2010 when National Joint Registry data highlighted higher than expected revision rates for metal-on-metal hip implants [78]. Primary care should be a rich source of data about musculoskeletal conditions, with one in five of the population consulting their GP each year about a musculoskeletal problem. Difficulties with standardisation of terminology and coding about musculoskeletal conditions can make primary care data difficult to interpret. The importance of primary care musculoskeletal data has at times been overlooked by policy makers [79,80]. Outcomes of clinical and public health interventions Morbidity can be harder to measure than mortality. Whereas for many other long-term conditions there are biomarkers (such as blood sugar, blood pressure or cholesterol) that can be used to monitor treatment outcome, this is not the case in musculoskeletal conditions where such outcome biomarkers do not exist. Instead, symptoms such as pain, disability, fatigue, reduced dexterity, and inability to participate socially act as markers of health status. Patient reported outcome measures (PROMs) are therefore ideal for use in musculoskeletal health, where conditions vary but symptoms such as pain and stiffness are generic. Currently the NHS only routinely uses musculoskeletal PROMs for the small fraction of people with musculoskeletal conditions that require or seek knee or hip surgery. Arthritis Research UK is funding the development and testing of the Arthritis Research UK MusculoSkeletal Health Questionnaire (MSK-HQ), intended for routine, longitudinal use across a wide number of musculoskeletal conditions [81]. Multiple indicators could be used to monitor musculoskeletal health outcomes at population level. Some of these relate to workplace participation, where musculoskeletal conditions are the second largest cause of work absence. These include receipt of employment and support allowance or fit notes relating to musculoskeletal problems. Other indicators include receipt of social care services, including home adaptations and individual care. Agreement is needed within the United Kingdom, and ideally beyond, about which indicators are most useful in this context and should be monitored. Barriers to the data linkage required to monitor such indicators will need to be addressed to achieve this, such as the lack of a common identification number across health and social care services and benefits systems. Conclusion A public health approach to musculoskeletal health is appropriate given the scale of the problem and the existence of amenable risk factors. With an ageing population, rising obesity and physical inactivity, and constrained health and social care budgets, a public health approach is needed to identify and modifying risk factors, recommend cost-effective interventions and prevent disability. A

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public health approach would benefit individuals through reduced pain and disability, and wider society by addressing lost productivity to the economy and increased health and social care costs. People at every stage of life should be supported to maintain and improve their musculoskeletal health and reduce their risk of developing a musculoskeletal condition in the future. For people with arthritis and other musculoskeletal conditions, perceptions must change that nothing can be done. Everyone can improve their own musculoskeletal health at every stage during their lives. People should be empowered with knowledge about keeping their own bones, joints and muscles healthy. Local communities should be resourced and enabled to develop support systems for people living with painful long term conditions. The public health system should create an environment where musculoskeletal health is seen as a priority and barriers to good musculoskeletal health are removed. All health and care professionals can introduce a public health approach to their practice by encouraging self-management, addressing widely-held misconceptions about the inevitability of musculoskeletal conditions, and offering brief interventions to support lifestyle changes. More specialist public health skills are also needed to support health services including robust population health needs assessment, service planning and evaluation, and promoting health service innovations that support self-management. Although some of the most important risk factors for musculoskeletal conditions are generic across non-communicable diseases, musculoskeletal health must be explicitly considered in public health programmes. First, so that the full benefits of tackling these risk factors can be appreciated by public health practitioners and policy makers. Second, so that in appropriate health beliefs about existing musculoskeletal conditions can be addressed, for example, that nothing can be done or that rest is better than activity. Third, so that musculoskeletal pain as a potential barrier to physical activity can be explicitly addressed by health and fitness professionals and policy makers, enabling people with pain to engage in appropriate physical activity. Fourth, promoting the benefits for musculoskeletal health of increased physical activity and reduced obesity may provide a unique opportunity to encourage lifestyle change because the links between physical inactivity, obesity and the development of musculoskeletal conditions may be relatively intuitive for the public. Finally, there needs to be a concerted effort by policy makers, the clinical community and the public health community to improve the quantity and quality of data about musculoskeletal health and musculoskeletal conditions to guide health and social care policy, to target and monitor health improvement programmes and activities, and to support quality improvement in services generally. Coordinating indicators and data strategies within and between health and care systems will allow for accurate comparison of health outcomes and improve the quality of service evaluations.

Summary An ageing population and finite health and social care resources means a shift from treating musculoskeletal disease to promoting lifelong musculoskeletal health is not only an ideal but an imperative. The high prevalence of musculoskeletal conditions and the modifiable risk factors require a public health approach to reduce both the incidence and impact of musculoskeletal conditions and make effective, lasting and meaningful improvements in the musculoskeletal health of the population. Such an approach has the potential to prevent disability, improve quality of life, deliver cost-savings for health and social care, and address lost productivity to the economy. A comprehensive public health approach to musculoskeletal health should build on generic public health activities to include condition-specific approaches such as:  reducing risk factors with specific reference to musculoskeletal conditions  changing incorrect population health beliefs and supporting self-management  implementing a public health approach to health and care services  improving musculoskeletal health in the workplace  providing high quality data about musculoskeletal health The last of these is a critical component underpinning a public health approach, and will require a concerted effort by policy makers, clinicians and the public health community to improve the quantity and quality of data about musculoskeletal health and musculoskeletal conditions to guide health and social care policy, to target and monitor health improvement programmes and activities, and to support quality improvement across musculoskeletal services.


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Practice recommendations  Public health messaging about obesity and physical inactivity should include the link between these risk factors and developing musculoskeletal conditions  All health and care professionals involved in the care of patients with musculoskeletal conditions should challenge the notion that “nothing can be done”, promote self-management, and offer brief interventions to support lifestyle changes  The benefits of weight loss and physical activity in particular should be emphasised to people with musculoskeletal conditions  The scope, quality and availability of data relating to musculoskeletal health should be urgently improved  Local and national assessments of population health should include burden due to musculoskeletal conditions

Research recommendations  Well-designed qualitative studies are needed to investigate the motivations and barriers to self-management of musculoskeletal conditions  Robust trials, as well as pragmatic real-world evaluations, are needed to investigate the efficacy of different modes and intensity of exercise for different musculoskeletal conditions  Mixed method studies are needed to investigate the most effective methods of promoting physical activity and healthy body weight among people at risk of, or who have already developed, musculoskeletal conditions  The extent, role and impact of musculoskeletal conditions upon multimorbidity and frailty should be investigated and characterised  Novel approaches to improving musculoskeletal health in the workplace should be investigated and evaluated

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A public health approach to musculoskeletal health.

An ageing, physically inactive and increasingly obese population, coupled with finite health and social care resources, requires a shift from treating...
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