Impact of Musculoskeletal Conditions

Eular On-line Course on Rheumatic Diseases module n3 Anthony D Woolf, Bruce Pfleger, Stefan Bergman
CLINICAL EPIDEMIOLOGY IMPACT OF MUSCULOSKELETAL CONDITIONS

Anthony D Woolf, Bruce Pfleger and Stefan Bergman
Anthony D Woolf, BSc, MBBS, FRCP Professor of Rheumatology Peninsula Medical School Duke of Cornwall Department of Rheumatology Royal Cornwall Hospital, Truro TR1 3LJ, UK Bruce Pfleger World Health Organization Chronic Diseases Prevention and Management Department of Chronic Diseases and Health Promotion 20 Avenue Appia CH-1211 Geneva 27 Switzerland Stefan Bergman, MD, PhD Research Director Research and Development Centre Spenshult Hospital SE 313 92 Oskarstrm Sweden
1
2007-2008 EULAR
Learning objectives: After following this module the student will be able to 1. Understand how the burden of musculoskeletal conditions can be measured 2. Know the burden of various major musculoskeletal conditions 3. Understand how a health condition can affect a person in terms of the WHO International Classification of Functioning, Disability and Health (WHO ICF) 4. Understand the importance of case definition when measuring burden of disease and the difficulties when considering musculoskeletal problems or specific conditions 5. Know how to measure burden of a given musculoskeletal condition in a given population 6. Know how to measure cost of illness in a given population
INTRODUCTION Musculoskeletal conditions are common and their impact is pervasive. Understanding their impact will lead to development and prioritisation of strategies for their prevention and management as well as the recognition of the need for advancing knowledge through research. Understanding the epidemiology of the various musculoskeletal conditions will give a better understanding of causes, risk factors for the conditions or their outcome as well as enabling the monitoring of secular trends.
WHAT ARE MUSCULOSKELETAL CONDITIONS? Musculoskeletal problems and conditions are common and their impact is pervasive. They are the most common cause of severe long-term pain and physical disability affecting hundreds of million people around the world. They are a major burden on health and social care. Musculoskeletal problems are most often characterised by pain and physical disability. These symptoms can sometimes be ascribed to specific musculoskeletal conditions but often the exact cause is unclear and they are described by the region that is symptomatic, such as low back pain. An important notion is that an apparently regional pain problem in about half of the cases is part of a more widespread pain problem, which may account for most of the burden. Musculoskeletal problems and conditions are diverse. For simplicity they may be grouped under a few major headings: (1) joint conditions e.g. rheumatoid arthritis, osteoarthritis (2) bone conditions e.g. osteoporosis and associated fragility fractures, (3) spinal disorders e.g. low back pain, (4) regional and widespread pain disorders, (5) musculoskeletal injuries e.g. high energy limb fractures, strains and sprains often related to occupation or sports and (6) genetic, congenital and developmental childhood disorders. Those problems and conditions not related to injuries or traumas are sometimes called rheumatic diseases and those predominantly affecting joints are collectively called arthritis. However musculoskeletal problems is a useful term to describe symptoms affecting the musculoskeletal system, whereas musculoskeletal conditions can be used when a cause is known. The pathophysiology of these problems and conditions is varied and not fully understood. Some have clear pathophysiological mechanisms whereas others have more complex biopsychosocial mechanisms.
2
2007-2008 EULAR
HOW CAN THE BURDEN OF MUSCULOSKELETAL PROBLEMS AND CONDITIONS BE MEASURED Definitions The measurement of burden needs clear definitions to be able to identify cases with consistency. The definitions will depend on the purpose. Identifying those with musculoskeletal pain will give an overview of the numbers who have any kind of problem but without knowing the consequences of the pain, its presence alone is of little value. It is more relevant to know who has musculoskeletal pain that affects their everyday activities. There is also a need to know who has certain musculoskeletal conditions such as rheumatoid arthritis or osteoporosis and for each condition a specific case definition is needed. Case definition can be based on clinical features, laboratory tests or imaging studies. However, a diagnosis by laboratory tests or imaging alone, such as joint space narrowing to determine the presence of osteoarthritis, is of little value in burden assessment unless symptoms are also present since there is no real impact on functioning. When measuring burden, objective case identification and an impact on functioning are necessary to identify disability. This issue is further considered in an in-depth discussion (See In-Depth discussion).
Incidence and prevalence The number of people affected by a musculoskeletal condition can be considered in different ways. Incidence refers to the number of new cases occurring over a predefined time period while prevalence refers to the number of existing cases for a population at either a particular point in time (point prevalence) or during a specified period (period prevalence). Conditions in which the point of onset is clearly identifiable, such as fractures resulting from trauma, lend themselves well to measures of incidence. However, as most musculoskeletal conditions have a gradual progressive onset, it is problematic to determine when a condition such as osteoarthritis or osteoporosis becomes a definable case. In this regard, measures of prevalence are more easily realized.
At risk population The burden can also be considered in terms of the at risk population. For this the determinants and risk factors of musculoskeletal health needs to be understood. The level of risk that is considered to be relevant and the timing of the event also need defining. Is it the lifetime risk of developing a condition or sustaining an event or is it the risk over a shorter defined period? For example fracture risk is sometimes expressed as lifetime risk after the age of 50 years or as the probability of sustaining a fracture over the next 10 years.
Impact of musculoskeletal conditions The impact on those who have been identified as affected must be measured in terms of the individual consequences as well as those on the population and the consequences for society (Table 1).
3
2007-2008 EULAR
Table 1 Measuring the Burden of Musculoskeletal Conditions What information is needed to measure the burden of musculoskeletal conditions: Case definitions Incidence Prevalence Remission Numbers at risk Impact on individual: Function and structure Activities Participation Mortality Impact in the population Summary measure of health Impact on society Resource utilisation: healthcare and rehabilitation Social consequences: work loss and social support Impact on the individual The consequences for the individual vary from short-term pain and impaired activity to premature death. This impact can be considered within the concept of the WHO International Classification of Functioning, Disability and Health (ICF)(1) (Figure 1 WHO International Classification of Functioning, Disability and Health (ICF)). This considers the impairment of body functions and structures, limitation of activities, and the restriction of participation that may relate to the health condition. All these will be influenced by both environmental and personal contextual factors. The impact on body structures can be assessed, for instance, by loss of bone mass or fracture in osteoporosis or loss of cartilage in osteoarthritis. Generic and disease-specific instruments are used to measure limitation of activities and restriction of participation. This is more fully considered in an in-depth discussion (See In-Depth discussion). Mortality associated with various musculoskeletal conditions must also be measured. This is generally fairly low with the exception of that associated with hip fractures resulting from osteoporosis.
Impact in the population In order to describe the burden of disease in a population adequately that allows comparisons between conditions and between populations, a summary measure is needed which represents the health of the population. This is intuitively appealing but extremely complex from the epidemiological standpoint. There are some key challenges for summary measures. How does one describe health states in a way that enhances cross-population comparability? How to measure the gap in the health of a population between its current position due to the condition being considered and some ideal standard for the whole population? What are the critical domains of health that need to be measured and monitored in order to describe the burden of disease adequately? A summary measure of the burden of musculoskeletal conditions requires a model of the condition along with the numbers of individuals within and moving between the different stages as well as their health-state at each stage of the condition. In most musculoskeletal conditions, people pass from normal health to being at risk and then developing clinical manifestations.
4
2007-2008 EULAR
Many of these musculoskeletal conditions are persistent and progressive and the person will move from an early and/or mild stage to a late and/or severe stage. The nature of the impact on the individual will vary at each stage and this is described by the health-state. The health-state is measured by the impact on the relevant domains. The most important health domains for musculoskeletal conditions have been considered to be overall wellbeing, general health, physical health, social health, mental health and barriers to participation (2). The characterisation of healthstates for the different stages of musculoskeletal conditions needs to be further developed if the true impact is to be determined and models of the stages of the different musculoskeletal conditions and the related health-states are being developed. Impact on society The cost to society as well as to the individual must be considered. It is the economic cost which often has most influence on priority-setting for strategies for prevention and treatment. The socioeconomic impact can be considered in terms of resource utilization by healthcare and rehabilitation and the costs of work loss and social support. In addition, the intangible costs, such as lost opportunities for the person or their career, are very significant for chronic disabling conditions but cannot be easily measured.
ASSESSING THE BURDEN OF MUSCULOSKELETAL PROBLEMS AND CONDITIONS IN PRACTICE The World Health Organization began collaboration with epidemiologists and disease experts to estimate the burden of various conditions and disease groups beginning with data for the year 1990. The objectives of the 1990 Global Burden of Disease (GBD) study included: (1) obtaining internally consistent estimates of mortality by age, sex and region for 107 causes, (2) obtaining internally consistent estimates of incidence, prevalence, case-fatality and duration by age, sex and region for 483 disabling sequelae, (3) estimating the burden of disease attributable to 10 major risk factors, and (4) project the burden of diseases to the year 2020. The year 2000 study expanded upon this to include an additional 30 conditions and 10 risk factors. The tree structure of causes essentially divides conditions into three categories: communicable, noncommunicable and injuries; musculoskeletal conditions fall in the second category. The 1990 study stratified data into eight regions based mostly on geography and partly on development while the 2000 study established 17 regions based on geography and mortality level. The five age groups chosen or 1990 were expanded to eight for 2000, which notably provided additional delineation at the older ages. The 1990 study was published as a series of volumes (3;4); while the results of the 2000 study appeared in the World Health Report series beginning in 2001 (5). Several updates have since been made including estimates of future disease patterns and there is a full revision in progress at present.
The two primary outcome measures for the GBD work include deaths and Disability Adjusted Life Years (DALYs). The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as the loss of one year of healthy life. DALYs used in burden measurement are the gap between current health status and an ideal situation where everyone lives into old age free of disease and disability. DALYs are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition: DALY = YLL + YLD
5
2007-2008 EULAR
The years of life lost (YLL) basically correspond to the number of deaths multiplied by the standard life expectancy at the age at which death occurs. The basic formula for YLL (without yet including other social preferences), is the following for a given cause, age and sex: YLL = N x L where: N = number of deaths L = standard life expectancy at age of death in years To estimate YLD for a particular cause in a particular time period, the number of incident cases in that period is multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (disease state equivalent to death). YLD = I x DW x L where: I = number of incident cases DW = disability weight L = average duration of the case until remission or death (years) Figure 2 displays a general disease model (Figure 2 General Disease Model). The model is modified as necessary for specific diseases and conditions. The four parameters specific to the model include: incidence or prevalence rate remission rate cause specific mortality rate natural mortality rate. The last parameter can be obtained through mortality tables, while the other three must be determined for each specific condition. In practice a computer programme called DISMOD is used to calculate the outcome measures. The software was developed at Harvard University for WHO burden work and derives epidemiological measures consistent with the assumed levels of incidence, remission, and case fatality. It is more realistic than assuming prevalence is the product of incidence and duration as it accounts for competing causes of mortality in an iterative fashion. This is particularly important for chronic conditions with low rates of remission and cause-specific mortality. Current methods allow for disease staging, with separate disability weights used for each stage. The percentage of a population with a condition falling into each of the stages must be estimated. The method is robust enough to allow for staging at each of the age groups used in the study and also allows for staging of treated and untreated forms of the disease. This means that one must also estimate the percentage of patients that receive treatment.
6
2007-2008 EULAR
MUSCULOSKELETAL PROBLEMS Pain is the most prominent symptom in most people with arthritis (6). In Europe, nearly a quarter of adults report having some form of arthritis or rheumatism. This may relate to one of the many known specific causes but may also be related to sprains and strains or work related activities. Musculoskeletal disorders are the commonest work related health problem. Often the symptoms cannot be attributed to any specific condition: for example back pain is most often non-specific in etiology. It is therefore simplest to call all problems that result in musculoskeletal symptoms, usually pain and disability, a musculoskeletal problem. Many of these will be attributable to a more specific diagnosis such as osteoarthritis, rheumatoid arthritis or gout. Musculoskeletal problems are a very common reason for primary care consultation (7) and a major basis for health care costs (8). Pain causes disability: pain is the most important determinant of disability in patients with osteoarthritis (9). Musculoskeletal conditions cause more functional limitations in the adult population in most welfare states than any other group of chronic disorders (Fig 3) (10). They are a major cause of YLDs in all continents and economies (Figure 4). In the 2002 WHO revised estimates of burden of disease, noncommunicable diseases accounted for 69% of all YLDs (communicable, 20%, injuries, 11%). Almost half of the noncommunicable disease burden is from mental health conditions, 31.7% of the overall. Musculoskeletal conditions represented 5.1% of all YLDs worldwide (RA 0.82%; OA 2.6%; gout 0.58%, low backpain 0.4%) which is expected to increase to 6.3% by 2030. Although many people are affected by musculoskeletal conditions, the level of disability for many is low to moderate and the major impact is in later life. As a consequence the YLDs attributable to them is not as high as one may have expected. Other high percentage categories include cancer 0.7%; diabetes 1.3%; sense organs 12.2% (blindness, deafness); cardiovascular 3.9%; respiratory 4.7%; digestive 3.5%; and congenital 2%. In the Ontario Health Survey (11) musculoskeletal conditions caused 40% of all chronic conditions, 54% of all long-term disability, and 24% of all restricted activity days. In surveys carried out in Canada, US, and Western Europe, the prevalence of physical disabilities due to a musculoskeletal condition has repeatedly been estimated to be 4-5% of the adult population (12). The prevalence is higher in women, and increases strongly with age. Musculoskeletal conditions are the main cause of disability in older age groups. They are the commonest cause of health problems limiting work in developed countries, and up to 60% of persons on early retirement or long-term sick leave claim musculoskeletal problem as the reason (13). In the Swedish Cost of Illness Study, musculoskeletal conditions were the most expensive disease categories representing 22.6% of the total cost of illness (14). The greatest costs related to morbidity and disability. Studies have shown that for osteoporosis and arthritis the healthcare costs only represent between a quarter and a third of the total costs.
OSTEOARTHRITIS Definitions Osteoarthritis (OA) is characterised by focal areas of loss of articular cartilage within synovial joints, associated with hypertrophy of bone (osteophytes and subchondral bone sclerosis) and thickening of the capsule. This phenomenon can occur in any joint, but is most common in selected joints of the hand, the spine, knee, foot and hip.
7
2007-2008 EULAR
This pathological change, when severe, results in radiological changes (loss of joint space and osteophytes) that have been used in epidemiological studies to estimate prevalence of OA at different joint sites. A Kellgren & Lawrence radiological OA score of 2-4 is still the most widely used definition of radiological OA in epidemiological studies (15). Clinically, the condition is characterized by joint pain, tenderness, limitation of movement, crepitus, occasional effusion, and variable degrees of local inflammation. Case definition can be based on pathological changes seen on x-ray, by the presence of joint symptoms or require both. It can also be related to the joints affected. If the prevalence is measured using radiological criteria alone, this can lead to overestimates of the burden of disease as radiological changes are not always accompanied by symptoms such as pain, stiffness, and loss of function. One study of women aged 45-65 in the UK showed that the prevalence of symptomatic knee OA was only 2.3% compared to 17% based on radiologically defined knee OA (16). The presence of knee pain without an examination or radiograph to confirm causation will also lead to an overestimate of prevalence. Likewise, surveys that ask for self-reported chronic conditions including osteoarthritis over-estimate the prevalence. The preferred definition for OA includes both xray findings and the presence of joint pain on most days (17).
Incidence and Prevalence Because of its gradual progressive development and the problems of definition of a new case, the incidence of osteoarthritis is problematic to estimate and there is little data. As OA is not reversible, the prevalence of OA increases indefinitely with age and this is where the burden lies. Males are affected more often than females below age 45, while females are affected more frequently after age 55 (18). An exception is OA of the hip where, in the 45-64 year age group males are affected more often than women. There are some ethnic and geographical differences in prevalence. African American females are more prone than Caucasian females to OA of the knee (19) but not for the hip (20). OA of the hip occurs more often in European Caucasians, than in Jamaican blacks(21), African or South African blacks (2;22;23), Chinese (24) or Asian Indians. The prevalence of osteoarthritis using radiographic criteria has been studied world-wide but data derives particularly from studies performed in the USA and Europe and these data have been reviewed and summarised (18). The two largest surveys are those from the US National Health Surveys (25) and the Zoetermeer Community Survey in the Netherlands (26). The latter survey was more extensive and included 22 joints and joint groups and found prevalence of knee osteoarthritis by radiological criteria of 14100 / 100,000 in men and 22800 / 100,000 in women over 45 years (27). Figure 5 shows estimates for osteoarthritis of the knee for seven regions of the world (Figure 5) (28). Hip OA is less common with a radiographic prevalence of 1945 / 100,000 in men and 2305 in women over 45 years in a Swedish survey (29). In many there will be several joints involved and it is estimated in the Global Burden of Disease study that approximately 10% of the worlds population who are 60 years or older have symptomatic problems that can be attributed to OA. There is little data on the incidence of OA because of the problems of determining its onset. The symptoms of osteoarthritis are not specific, and the radiological changes reflect a gradual pathological process for which no time of onset can be defined. It can be estimated by the number presenting to health care with OA by agreed criteria. An estimation of the incidence of severe osteoarthritis may be obtained from the figures of the progression of radiological osteoarthritis from a low to a higher Kellgren score, with or without the onset of clinical symptoms. Incidence has been estimated in Australia by using the DISMOD software package and estimates of prevalence, remission, casefatality rates and background mortality.
8
2007-2008 EULAR
This indicates that females have a higher incidence of osteoarthritis than males in all age groups and that, overall, they have an incidence of 2.95 per 1000 population, compared with 1.71 per 1000 population in males. For women the incidence of osteoarthritis is highest among those aged 6574 years, reaching approximately 13.5 per 1000 population per year; for men the highest incidence of approximately 9 cases per 1000 population per year occurs in those aged 75 years and over. The incidence of symptomatic OA of the knee was 1% per annum of women aged 70 - 89, which was less than half the incidence of hand or hip OA in a large scale study (N=130,000) in Massachusetts, USA (30). The incidence and rate of progression increases with age.
At risk population Age is the strongest predictor of the development and progression of radiographic OA. Almost everyone who reaches 90 years will have OA in some joint. OA is more common in females, increasing at the age of 50 especially in the hand and knee. The role of the menopause is unclear but hormone replacement therapy (HRT) is associated with a reduced risk of the development and progression of knee OA. Obesity (BMI) is a risk factor for the development of OA of the hand, knee and hip and for progression in the knee and hip (31;32). One study showed obesity to result in an odds ratio of about 8.0 for developing OA knee (33). It is estimated that a decrease of 2 BMI units would decrease the risk of developing knee OA by 20-30% (34). Trauma, particularly in men, is associated with development of knee OA. Other mechanical factors and intensive activity are risk factors for the development of OA of the knee and hip shown by associations with malalignment, repeated knee bends or squatting, intensive sports activities and certain physically demanding occupations (35). Farming presents the greatest relative risk for OA: 4.5 for farming 1-9 years and 9.3 for farming ten years or more (36). There is a negative association with osteoporosis and smoking (37). These risk factors are summarised in table 2.
9
2007-2008 EULAR
Table 2 Risk factors for incidence and progression of osteoarthritis of the knees, hips, and hands. Adapted from Petersson and Jacobson (ref)
Type of osteoarthritis Incidence Knee Strong Degree of evidence for association Intermediate Suggested
Hip Hand Progression Knee
Age Female sex Physical activity High body mass index Bone density Previous injury Hormone replacement therapy (protective) Age Age
Vitamin D Smoking (protective) Alignment
Quadriceps strength (protective) Intensive sport activities
Physical activity High body mass index Grip strength High body mass index Vitamin D Hormone replacement therapy Alignment Physical activity
Injury Intensive sport activities Occupation Intensive sport activities Intensive sport activities
Age
Hip
Age
High body mass index Intensive sport activities
Course of condition The course of the disease varies but is often progressive and the radiographic changes of osteoarthritis inexorably progress, albeit at a slow rate, in the hands (38), the knees (39), and the hips (40). This leads to increased pain and progressive disability (39). Progression of OA is accelerated by age, and in the hip and knee by obesity and intensive physical activity.
Impact Osteoarthritis of the hip and knee are the most important from the viewpoint of public health, based on their prevalence and associated disability. Osteoarthritis of the knee is a major cause of mobility impairment, particularly among females. OA was estimated to be the 10th leading cause of non-fatal burden in the world in 1990, accounting for 2.8% of total YLD, around the same percentage as schizophrenia and congenital anomalies(3). In the Version 1 estimates for the Global Burden of Disease 2000 study, published in the World Health Report 2001 (41), OA is the 6th leading cause of YLDs at global level, accounting for 3.0% of total global YLDs. Osteoarthritis results in pain, loss of motion of affected joints which limits related activities such as manual dexterity and mobility. It is the major contributor to lower limb disability. Its impact can be described by the health state descriptions that have been developed as part of the GBD 2000 project (Table 3).
10
2007-2008 EULAR
Table 3
Health state descriptions for osteoarthritis
Sequela/stage/sever ity level Osteoarthritis of the hip Grade 2 symptomatic Osteoarthritis of the hip Grade 3-4 symptomatic
Health state description Definite osteophytes and possible narrowing of joint spaces. Hip pain on most days. Availability of treatment (pain medication, antiinflammatories) may result in reduced pain and disability. Marked narrowing of joint spaces, definite osteophytes and deformity of femoral head. Hip pain on most days. Availability of treatment (pain medication, anti-inflammatories) may result in reduced pain and disability. Joint replacement likely in developed countries for Grade 4+ with significant disability (model this as reduction in prevalence of Grade 3-4 rather than reduced disability weight). Possible narrowing of joint spaces and definite osteophytes. Knee pain on most days, tenderness, morning stiffness and crepitus on active joint motion. Availability of treatment (pain medication, antiinflammatories) may result in reduced pain and disability. Around 8% of symptomatic cases with grade 2+ OA need assistance with stair climbing (compared to 2% of non-cases in Framingham study), 30% not able to walk a mile (compared to 14% non-cases), 11% needed assistance with housekeeping (cf. 6%). Definite or marked narrowing of joint spaces, multiple moderate to large osteophytes, and possible to definite deformity of bone ends. Knee pain on most days, tenderness, morning stiffness and crepitus on active joint motion. Availability of treatment (pain medication, antiinflammatories) may result in reduced pain and disability. Joint replacement may occur in developed countries for Grade 4+ with significant disability (model as reduction in prevalence).
Osteoarthritis of the knee Grade 2 symptomatic
Osteoarthritis of the knee Grade 3-4 symptomatic
Time trends Future changes in the incidence and prevalence of OA are difficult to predict. As incidence and prevalence rise with increasing age, extending life expectancy will result in greater numbers with OA. The burden will be the greatest in developing countries where improvements in life expectancy are expected and access to arthroplasty and joint replacement is not readily available.
RHEUMATOID ARTHRITIS Definitions Rheumatoid arthritis (RA) is an inflammatory condition with a clinical picture of widespread, synovial joint involvement. It is the most common form of chronic polyarthritis. The established disease is distinguished from other forms of arthritis by various criteria, and the set agreed by the ACR are usually used (42).
11
2007-2008 EULAR
However at the onset, inflammatory polyarthritis that will persist and develop the features of rheumatoid arthritis is difficult to distinguish from that which will resolve or progress into another form of chronic arthritis. There is much current research trying to resolve this and be able to identify rheumatoid arthritis at the earliest stage to enable early treatment, with markers such as anti-cyclic citrullinated peptide antibodies.
Incidence and Prevalence The incidence and prevalence of RA generally rises with increasing age until about age 70, then declines (43). Around twice as many women as men are affected. Incidence data on rheumatoid arthritis have mostly been collected in populations of Anglo-Saxon ethnicity (44). The incidence of rheumatoid arthritis is 20300 per 100 000 subjects per year; that of juvenile rheumatoid arthritis is 2050 per 100 000 subjects per year. Changes in the incidence and prevalence of rheumatoid arthritis are difficult to predict. Recent studies indicate a future decline in its incidence, particularly among women (16). On the other hand its incidence is expected to increase over the next 10 years in Europe because of the increasing proportion of older people. The net result, however, is unpredictable, so prospective figures should be gathered in specific studies. Data on the prevalence of rheumatoid arthritis derive largely from recently reviewed studies performed in the USA and Europe (44). The prevalence of rheumatoid arthritis in most industrialized countries varies between 0.3% and 1%, whereas in developing countries it is at the lower end of this range. Previously, few cases or none have been found in African surveys (Silman AJ, Hochberg MC. Epidemiology of the rheumatic diseases. Oxford: Oxford University Press, 1993). The prevalence in native American groups can be considerably higher (45). There may be a link to urban living as a study in Soweto (23) showed a prevalence of RA among urban blacks equivalent to that in white Europeans, while rural black groups have showed much lower prevalence (18). Figure 6 shows estimates of the prevalence of rheumatoid arthritis for seven regions of the world (Figure 6) (46).
At risk population RA tends to run in families. One of the genetic components of seropositive RA has been mapped to a short gene sequence now known as the shared epitope. This appears to be the marker for RA disease severity rather than susceptibility (47). The prevalence of the shared epitope varies considerably between populations. This may, in part, explain the different patterns of RA seen around the globe. Little is known about the environmental triggers for RA. Infection may play a part in some individuals. There are complex interactions between the female sex hormones and RA. The onset of RA is rare during pregnancy and RA is more common in nulliparous women. The oral contraceptive pill, or some other factor associated with its use, appears to protect against the development of the severe RA. Again the frequency of the pill use, nulliparity and breast-feeding varies considerably between communities and may influence the epidemiology of RA. Smoking and obesity are also risk factors for RA (48). Base line predictors of future functional disability in patients with early RA that have been identified in various cohorts include older age, female gender, longer disease duration at presentation, presence of rheumatoid factor, more tender and / or swollen joints and poorer function (49).
12
2007-2008 EULAR
Base line predictors of future radiological change in patients with early RA that have been identified in various cohorts include older age, female gender, longer disease duration at presentation, presence of rheumatoid factor and more tender and/or swollen joints (49).
Course of the condition Inflammatory polyarthritis has a remission rate of 30-40% in inception cohort studies and in population studies there is little evidence of persistent disease in 75% of people after 5 years. However the remission in those classified as already having RA at presentation is lower, around 10-30%. Clinicbased established cases have a far worse prognosis and until the 1980s most had significant progression over 10 years with few being controlled on symptomatic therapy alone. Spontaneous remission rates are only 5-7% with a median duration of 10 months. There is also an increased mortality associated with RA. Modern treatment is effective at controlling disease activity and reducing longterm disability and early treatment aimed at controlling disease activity is the present strategy to prevent this disability.
Impact RA is a more disabling disease (although not necessarily more painful) than lower limb osteoarthritis. The impact of RA is however changing due to advances in management and most data is with less aggressive approaches to treatment with less effective therapeutic agents than are currently used. Hakala et al (50) examined the severity of RA in a population study using 1987 ARA criteria and found that about two-thirds of cases had mild or moderate disability due to RA and less than 10% had severe disability. The disability starts early and rises in a linear fashion (51). Within ten years of onset, at least 50% of patients are unable to hold down a full-time job (52). Those whose disease starts early (before the age of 45) are more likely to become severely disabled than those whose disease starts at older ages (70+). There is no cure for RA but disease activity and long term disability can be improved with current disease modifying therapies. In addition to drug treatment, orthopaedic surgery is able to offer great relief to those particularly in the second and third decade of disease, who have been severely disabled. Physiotherapy and adaptations to the home may also reduce disability. It has been recently estimated that, with current management applied optimally, the burden of disability due to RA might be further reduced by 25% in developed countries. In low income countries, the appropriate infrastructure to provide adequate supervision of second-line drug therapy and to provide skilled orthopaedic surgery is often absent. In addition, steroid therapy is often freely available and used indiscriminately. It is estimated that the burden of disability due to RA might be reduced by 40% in these countries if medical input were increased. RA is associated with a reduced life expectancy. Mortality is generally greater in studies reporting patients in the clinic setting who usually suffer from a more severe form of the disease. There is some evidence that mortality amongst community based RA patients in developing countries is also very high (53) and this may, in part, account for the low prevalence in some of these countries. Mortality is related to severity of RA as expressed by functional status, health status and health status perception, radiological damage, and extra-articular manifestations. Co-morbidity, formal education, socio-economic and marital status, but not race, may affect survival.
13
2007-2008 EULAR
Time trends Future changes in the incidence and prevalence of RA are difficult to predict. Recent studies indicate a decline in its prevalence, particularly among women (54). On the other side, RA is expected to increase in the next 10 years in Europe and North America as a function of their ageing populations. The net result of these opposite trends, however, is unpredictable and prospective figures should be gathered through specific studies.
OSTEOPOROSIS AND LOW TRAUMA FRACTURES Definitions Osteoporosis is defined as a systemic skeletal disease characterized by a low bone mass and a microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. In 1994 a WHO expert panel (55) operationalized this concept by defining diagnostic criteria for osteoporosis on the basis of measurement of bone mineral density (BMD). Osteoporosis: a BMD value at least 2.5 standard deviations below the mean BMD of young adult women (BMD T-score 2.5). Osteopenia (low bone mass): a BMD value between 1 and 2.5 standard deviations below the mean BMD of young adult women (2.5 <BMD T-score <1). Clinically, osteoporosis is recognized by the occurrence of characteristic low-trauma fractures, the best documented of these being hip, vertebral and distal forearm fractures. A hip fracture is a fracture of the proximal femur, either through the femoral neck (subcapital or transcervical fracture, an intracapsular fracture) or through the trochanteric region (intertrochanteric or subtrochanteric fracture, an extracapsular fracture). Whether the aetiology of the two fractures also differs remains contentious. Some studies, but not all, have suggested that osteoporosis plays a greater role in causing extracapsular fractures than it does in causing intracapsular fractures. Vertebral fracture is seen as a deformity of the vertebra on x-ray, usually described as a crush (involving compression of the entire vertebral body), a wedge (in which there is anterior height loss) or as biconcave (where there is a relative maintenance of the anterior and posterior heights, with central compression of the endplate regions). The difficulty in deciding whether a vertebra is deformed arises from the variation in the shape of vertebral bodies both within the spine and between individuals. A morphometric approach is often used in studies and there are algorithms that compare the extent to which ratios between the anterior-, posterior- and mid-vertebral heights (corresponding to wedge, biconcave and crush deformities) differ from vertebra-specific mean values in the general population. Semiquantitative methods are also used, most often classifying vertebral deformities as mild (2025% height loss), moderate (2540% height loss) or severe (>40% height loss). Only between 10% and 30% of those who have sustained a vertebral deformity reach primary care in Europe (56) .
14
2007-2008 EULAR
Incidence and prevalence The incidence of osteoporosis is best measured indirectly as the incidence of fractures resulting from the condition (Figure 7). Prevalence is best measured by the frequency of reduced BMD or numbers of those with vertebral deformity. The lifetime risk or the 10 year probability of fracture can also be considered (57). The lifetime risk at the age of 50 of fragility fractures is considerable (Table 4). Table 4 Estimated lifetime risks of fractures in the UK at various ages Current age (years) Women 50 60 70 80 Men 50 60 70 80 Any fractures 53.2% 45.5% 36.9% 28.6% 20.7% 14.7% 11.4% 9.6% Radius/ulna 16.6% 14.0% 10.4% 6.9% 2.9% 2.0% 1.4% 1.1% Femur/hip 11.4% 11.6% 12.1% 12.3% 3.1% 3.1% 3.3% 3.7% Vertebra 3.1% 2.9% 2.6% 1.9% 1.2% 1.1% 1.0% 0.8%
Epidemiology of fractures in England and Wales Van Staa TP, Dennison EM, Leufkens HGM and Cooper C Bone 2001; 29: 517-22(57) Hip fracture In Western populations the incidence of hip fractures increases exponentially with age, with rates of 2/100,000 person-years in women aged under 35 years rising to 3032/100,000 person-years in women 85 years and older, with rates in men of 4 and 1909 respectively (58). Above 50 years of age there is a female to male incidence ratio of approximately 2:1. Overall, about 98% of hip fractures occur among people aged 35 years and older, and 80% occur in women (due in part to there being more elderly women than men). Worldwide there were estimated to be 1.66 million hip fractures in 1990, about 1.19 million in women and 463 000 in men. Most hip fractures occur after a fall from standing height or less in men or women with reduced bone strength. The risk of falling increases with age. Hip fracture may also occur spontaneously (59) These statistics apply principally to the incidence of hip fractures in Europe and the USA and data now available from other parts of the world shows that hip fracture occurs less frequently in non-white than in white populations. Incidence rates are extremely low in African countries and greater among Oriental populations. The highest incidence rates have been reported from northern Europe and the northern part of the USA.
15
2007-2008 EULAR
Vertebral fracture The prevalence of radiological findings increases with age and one in eight men and women over 50 years in Europe have vertebral deformity (Figure 8). The rates vary between populations with a demonstrated three-fold variation across Europe and up to two-fold variation within European countries in the EVOS study (60). Vertebral deformities in men at the earlier ages may represent developmental changes rather than fractures. The age-adjusted and sex-adjusted incidence rates for vertebral deformity are 1% per year among women and 0.6% per year among men from the European Prospective Osteoporosis Study (61) (Figure 9), and similar figures have been found in the USA. The age-adjusted incidence of clinically diagnosed vertebral fractures has been estimated for white women aged 50 years and over as 5.3 per thousand person-years, the comparable male rate being around half this figure, in the northern part of the USA. The majority of vertebral fractures are the result of compressive loading associated with activities such as lifting or changing positions, or have been discovered only incidentally. Only a third of new vertebral fractures relate to falls. Distal forearm fracture Most distal forearm fractures occur in women (the age-adjusted female to male ratio being 4:1), and around 50% occur in women aged 65 years and older. A recent multicentre study in the United Kingdom found annual incidences of 9 and 37 per 10 000 men and women respectively, with hospitalization rates of 23% and 19% respectively (60). There was a tendency for the incidence rate of distal forearm fracture to continue to increase after the age of 70 years among women, perhaps pointing to increasing frailty in the elderly female population of Western countries throughout the last decade of the twentieth century and the first decade of the twenty-first. Other fractures The majority of fractures in subjects aged over 50 years are the result of osteoporosis. The incidence rates of proximal humeral, pelvic and proximal tibial fractures also rise steeply with age and are greater in women than in men. About 80% of proximal humeral fractures occur in individuals aged 35 years and over, three-quarters occurring in women. Similar patterns have been observed for distal femur fracture and fractures of the rib, clavicle and scapula. Bone mineral density The risk of fracture rises when the BMD declines, and the WHO operationalized this concept by considering osteoporosis to be present when the BMD level in women was 2.5 standard deviations or more below the normal mean for young women. It is estimated that 54% of postmenopausal white women in the northern USA have osteopenia, and a further 30% have osteoporosis in at least one skeletal site. In the United Kingdom, it is estimated that around 23% of women aged 50 or more have osteoporosis as defined by WHO. The proportion increases steeply between the ages of 50 and 80 years. The International Osteoporosis Foundation has recommended that, for the purposes of diagnosis as opposed to those of assessment, BMD should be measured at the hip using dual-energy X-ray absorptiometry and on these criteria the general prevalence of osteoporosis rises from 5% in women at the age of 50 years to 50% at the age of 85, and in men the comparable figures are 2.4% and 20% (62).
16
2007-2008 EULAR
At risk population Apart from age and female gender, the major determinants of fracture are falling, low bone mass, i.e. osteoporosis, and previous low trauma fracture. There are risk factors that identify those more likely to fall (Table 5) and those who may have osteoporosis or at risk of fracture (Table 6). There are some semi-independent risk factors for fracture such as bone turnover as assessed by bone markers. Frailty and co-morbidity are also risk factors for poor outcome of fracture.
Table 5 Risk Factors for Falling in the Elderly Risk Factors for Falling in the Elderly Intrinsic factors General problem
General deterioration associated with aging
Specific problems
Balance, gait or mobility problems
Visual impairment
Impaired cognition or depression Blackouts
Poor postural control Defective proprioception Reduced walking speed Weakness of lower limbs Slow reaction time Various comorbidities Joint disease Cerebrovascular disease Peripheral neuropathy Parkinson's disease Alcohol Impaired visual acuity Cataracts Glaucoma Retinal degeneration Alzheimers disease Cerebrovascular disease Hypoglycaemia Postural hypotension Cardiac arrhythmia TIA, acute onset cerebrovascular attack Epilepsy Drop attacks ?VBI Inappropriate footwear or clothing Sedatives Hypotensive drugs Bad lighting Steep stairs, lack of grab rails Slippery floors, loose rugs Tripping over pets, grandchildren's toys etc Cords for telephone and electrical appliances Uneven surfaces: pavements, streets, paths Lack of safety equipment such as grab rails Bad weather: snowy and icy conditions Traffic and public transportation
Extrinsic factors Personal hazards Multiple drug therapy Environmental factors Indoor / home hazards
Outdoor hazards
17
2007-2008 EULAR
Table 6 Risk factors for bone loss, development of osteoporosis and for fracture in the elderly (excluding falls) Risk Factors for Bone Loss, Osteoporosis and Fracture in the Elderly Aging (> 75 years) Female Previous fracture following low energy trauma Radiographic evidence of osteopenia or vertebral deformity or both Loss of height, thoracic kyphosis (after radiographic confirmation of vertebral deformities) Low body weight (BMI < 19kg/m2) Corticosteroids (prednisolone (or equivalent) 75 mg per day or more with an expected use of more than 6 months) Family history of osteoporotic fracture (maternal hip fracture) Reduced lifetime exposure to estrogen (primary or secondary amenorrhoea, early natural or surgical menopause (<45 years)) Various disorders associated with osteoporosis (previous low body weight, rheumatoid arthritis, malabsorption syndromes, including chronic liver disease and inflammatory bowel disease; primary hyperparathyroidism; long-term immobilisation) Behavioural risk factors o Low calcium intake (<500-850 mg/day) o Physical inactivity o Vitamin D deficiency (low sunlight exposure) o Smoking (current) o Excessive alcohol consumption
Bone density has the strongest relationship to fracture but many fractures will also occur in women without osteoporosis. The possibility of fracture increases when combining low bone density with the presence of other risk factors for fracture. In particular bone density combined with risk factors that are at least partly independent of bone density (63) can identify those at much increased risk of fracture but the exact interaction of different risk factors is not established. Identification of high risk patients is at present dependent on evaluation of their individual relative risk based on information gained from epidemiological studies. This will not with certainty predict who will fracture as no risk factor singly or in combination is of sufficient sensitivity for an acceptable specificity. However interventions to prevent fracture, like the prevention of any other condition, have to be aimed at those individuals in whom the balance of risks and costs is in favour of treatment. This may lead to treating some who would not have sustained a fracture. Efforts are being made to use existing data to describe the absolute risk for the individual patient over a time period that is comprehensible, that is 5 to 10 years (64) (Table 7). This will strengthen the indication for intervention and should improve compliance. An analysis of risk factors in the absence of bone mineral density will also assist in identifying those in need of such a measure, helping to reduce diagnostic costs (BMD measurement is not necessary in low risk patients or in those at highest risk).
18
2007-2008 EULAR
Table 7 Estimated 10 year risks of fractures in the UK at various ages Current age (years) Women 50 60 70 80 Men 50 60 70 80 7.1% 5.7% 6.2% 8.0% 1.1% 0.9% 0.9% 0.9% 0.2% 0.4% 1.4% 2.9% 0.2% 0.3% 0.5% 0.7% Any fractures 9.8% 13.3% 17.0% 21.7% Radius/ulna 3.2% 4.9% 5.6% 5.5% Femur/hip 0.3% 1.1% 3.4% 8.7% Vertebra 0.3% 0.6% 1.3% 1.6%
Epidemiology of fractures in England and Wales (57)
Course of condition A classical case of osteoporosis may present in a woman about 55 years of age with a wrist fracture. Ten years later she may present with back pain, with or without minor trauma, and thoracolumbar spine X-rays may show a vertebral fracture. She might have one of several risk factors: low body weight, premature menopause, a family history of fractures, smoking, heavy alcohol consumption, inactivity, calcium or vitamin D deficiency or corticosteroid use. The back pain may remit and relapse with subsequent vertebral fractures. Approximately 1015 years later, at the age of 7580 years, the patient may fall and sustain a hip fracture, resulting in hospitalisation, a 20% excess risk of death, considerable functional impairment and possibly a loss of independence if she survives. Although this scenario is instantly recognizable, osteoporosis may present with any of a wide range of fractures and at a variety of ages; it is also increasingly recognized among men.
Impact Hip fracture results in pain, loss of mobility and excess mortality. Nearly all are hospitalised and most undergo surgical repair of the fracture or replacement of the joint. At 1 year hip fracture is associated with 20% mortality, 50% loss of function and only 30% have regained all prior function (65;66). Many loose their independence and require longterm care. Only half those surviving a hip fracture will walk again and often not to the same level as prior to the fracture (66;67). Acute vertebral fracture affects quality of life with limitation of activities and restriction of participation. Up to a fifth are hospitalised and some will require subsequent longterm care, particularly those of advanced age or with comorbidity. Pain and loss of spinal movement cause most limitation. Chronic vertebral osteoporosis, with compression fractures and deformities, is associated with pain and longterm impairment of quality of life. Pain and disability worsen with each new vertebral fracture, with an increasing total number of vertebral fractures and with worsening of spinal deformity. Lumbar fractures have most impact. The QUALEFFO has been developed as an instrument to specifically assess the impact of osteoporosis on quality of life and all domains are affected, with pain being worst.
19
2007-2008 EULAR
This impact has also been demonstrated using generic health-related quality of life instruments. The effect is not just due to recent fracture as it has been demonstrated several years after the fracture. Physical performance declines even in the absence of significant pain, and undiagnosed vertebral fractures are associated with disability. Co-morbidity is common at this advanced age and contributes to the impact on quality of life and increased mortality. The decline in physical function and changes in appearance contribute to social isolation, loss of self-esteem. Colles fracture results in hospitalisation rates of 23% of men and 19% of women (60;66). Only 50% report a good functional outcome at 6 months (66;68). Mortality Mortality has been studied in hip fracture patients during the first year after fracture has occurred. In urbanized countries, mortality is high in the first year, perhaps up to 25% in women and 35% in men. Comorbidity is an important contributory factor in hip fractures and a determinant of outcome (66;69). Vertebral fractures are also associated with an increased mortality at 5 years as seen with hip fracture, but is gradual over the 5 year period. No excess mortality is associated with wrist fractures (70-72). Time trends The number of hip fractures is increasing throughout the world and the projected number in 2050 is 6.3 million worldwide. The increase will affect Asian populations in particular and it has been estimated that more than half of all hip fractures worldwide will occur in Asia by 2050 (73) (Figure 10).
LOW BACK PAIN Definitions Low back pain is a major health and socio-economic problem in Western countries. Many people will experience one or more episodes of low back pain in their lives. It is usually defined as pain localised below the line of the 12th rib and above the inferior gluteal folds (74), with or without leg pain. It is simplest defined in practical terms by using a body manikin. It is usually classified as being specific or non-specific. Specific back pain is defined as symptoms caused by a specific pathophysiologic mechanism such as prolapsed intervertebral disc, infection, spondyloarthropathy, fracture or tumour. Such specific causes account for about 10% of cases whereas 90% of people with low back pain have no clearly defined pathophysiologic cause. Non-specific low back pain is usually classified according to duration and recurrence. Acute back pain is of less than 6 weeks duration; subacute is between 6 weeks and 3 months duration and chronic when it lasts more than 3 months (75). Frequent episodes are described as recurrent back pain. Incidence and prevalence Back pain is very common but the prevalence varies according to the definitions used and the population studied.
20
2007-2008 EULAR
There are not many studies of incidence but a large study from the Netherlands reported an incidence of 28.0 episodes / 1000 persons per year and low back pain with sciatica was 11.6 / 1000 persons per year, affecting men a little more than women and is most frequent in the working population being highest between 25 and 64 years (76). New episodes are twice as common if there is a history of previous low back pain. Lifetime prevalence varies between 58% and 84%, point prevalence (proportion of population studied that are suffering back pain at a particular point of time) between 4% and 33%. At risk population The occurrence of low back pain is associated with age, physical fitness, smoking, excess body weight and strength of back and abdominal muscles. Psychological factors associated with occurrence of back pain are anxiety, depression, emotional instability and pain behaviour. Occupational factors clearly play a role such as heavy work, lifting, bending, twisting, pulling and pushing as well as psychological workplace variables, such as dissatisfaction. It is important to prevent chronicity as that is where the impact on the individual and society is greatest. Obesity is a risk factor. However, psychosocial aspects of health and work in combination with economic aspects appear to have more impact on work loss than physical aspects of disability and physical requirements of the job. Course of condition Most episodes of low back pain settle after a couple of weeks but many have a recurrent course with further acute episodes affecting 20 44% within 1 year in the working population and lifetime recurrences of up to 85% (77). Frequently it never fully resolves and is characterised by exacerbations of chronic low back pain. Many people with chronic low back pain also have widespread pain which adds to its burden. Impact Back pain has a marked effect on the individual and also on society due to its frequency and economic consequences. The problem is defined by pain, which is often persistent during the episode and many do not have complete resolution of their symptoms and have flares on a background of chronic pain. Pain is often worse with prolonged walking, standing and sitting which restricts mobility as well as travelling any distance in a vehicle. Sleep is often disturbed and some have chronic widespread pain in addition. Strenuous activities as well as leisure pursuits may be prevented during the episode of back pain by worsening of the pain and after the episode by fear of recurrence. Most return to work within 1 week with 90% returning within 2 months, but the longer on sick leave the less likely the person is to return to work. After 6 months off work, less than 50% will return to work and after 2 years absence, there is little chance of returning. Because of this and its frequency, the costs to society are enormous. About 90% of the cost of back pain is indirect due to work loss and disablement reflecting its frequency among the working population. The costs are mainly incurred by 10 25% of those with back pain in whom it persists for more than 1 month. In cases with chronic back pain the impact on health and low frequency of return to work probably reflects that about 50% of cases are associated with a non-specific widespread pain condition.
21
2007-2008 EULAR
Time trends There has been a reported increase in prevalence in the UK between 1980 and 2000 (78) but this is interpreted as related to a greater awareness of minor back symptoms and willingness to report them. Such cultural changes in other parts of the globe, where back pain is not considered by many a condition associated with disability, could lead to an enormous increase in the burden.
SOCIETAL IMPACT Musculoskeletal conditions have a major impact on society due to their frequency, chronicity and resultant disability. This has major cost implications and it the economic burden that is of importance to policy makers when prioritizing resources for health and social care. Most of the costs are indirect related to work disability and social care and a minority of costs relates to the direct costs of health care, although these are not without significance. The direct costs will increase with more expensive and widespread treatments for rheumatoid arthritis and osteoporosis and the aging population needing more arthroplasties for osteoarthritis. There are many domains that need to be considered when considering the economic impact of musculoskeletal conditions (Table 8). The work disability and utilization of health resources will be considered here.
Work disability In addition to functional limitations in everyday life, work disability is a major consequence of disease for the individual. A chronic pain condition might lead to permanent or temporary loss of work ability. Permanent disability in the economically active population can be estimated on basis of register data on disability pensions. Temporary disability, on the other hand, might be the consequence in milder cases with varying intensity of complaints, and can be estimated from sick leave or workers compensation claims. A hindrance to these estimates is the lack of consistent diagnoses or causes given to such claims. Musculoskeletal complaints are a major cause of sickness absence, as shown from Scandinavia (79), Poland (80), UK, and the US (81). In short term sickness absence (less than 1-2 weeks), musculoskeletal health complaints are second only to respiratory disorders (82). Musculoskeletal complaints are the most common medical causes of long term absence, which is more important than short term absence for the individual in terms of consequences and for society in terms of costs. Musculoskeletal injuries and disorders cause more than half of all sickness absence longer than two weeks in Norway (83). It is difficult to determine precisely the sickness absence that is caused by the different musculoskeletal conditions because of validity of diagnosis but a Norwegian study found that 33% of those persons with sick leave over 4 days had low back pain, 20% neck and shoulder disorders whereas only 3% had rheumatoid arthritis (Table 9).
22
2007-2008 EULAR
Table 8 Domains of health economic impact relevant to musculoskeletal conditions Category Domains How to identify costs Direct costs Health care costs
Outpatient costs Visits to physicians (primary care and specialist) Outpatient surgery Emergency room Rehabilitation service utilisation (physiotherapist, occupational therapist, social worker etc) Medication (prescription and non-prescription) Diagnostic / therapeutic procedures and tests Devices and aids Acute hospital facilities (without surgery) Acute hospital facilities (with surgery) Non acute hospital facilities Personal costs Transportation Patient time Carer time Home health care services Environmental adaptations Medical equipment (non-prescription) Non-medical practitioner, alternative therapy Nursing home or residential home Home care services Indirect costs Productivity costs
Hospital or insurer activity data of visits
Inpatient costs
Other disease related costs
Change of living status
Pharmacy records Radiology activity Laboratory tests, Provision of equipment Hospital or insurer activity data of admissions, lengths of stay, procedures Rehabilitation activity Nursing home activity Transportation distance, frequency, methods Time spent in healthcare Time spent giving care Home health care activity Home, work and transportation adaptations Equipment provision Therapist activity Nursing and residential home activity, Formal and informal home care activity Sick leave, lost wages, work disability benefits, number no longer working, disabilities leading to impaired housekeeping or activities of daily living, loss of productivity Survey Difficult to quantify
Loss of productivity in employed patients or their carers Opportunity costs reduced employability at present or higher level
Out of pocket Intangible costs
Out of pocket expenses Deterioration in quality of life of patient, family, carers, friends
23
2007-2008 EULAR
Table 9 Distribution (in per cent) of persons with sick leave longer than 14 days due to musculoskeletal and connective tissue disorders by diagnosis and gender. Norway, 1994 Diagnosis Men Women Total N=75 228 N=81 416 N=156 644 Low back disorders 35 31 33 Neck and shoulder disorders 16 23 20 Musculoskeletal injuries 23 12 17 Tendinitis, epicondylitis, ganglion 6 7 7 Rheumatoid arthritis 3 3 3 Osteoarthritis 2 2 2 Muscle pain/fibromyalgia 0.5 2.4 1.5 Other musculoskeletal disorders 15 19 17 100 100 100 Sum
Musculoskeletal complaints are also common causes for disability pensions, along with mental disorders and cardiovascular disorders. The relative importance of these three groups varies, but in several countries, the mental and musculoskeletal disorders are 2-4 times more frequent than cardiovascular disorders as causes for disability pensions. In Norway, low back disorders are the commonest reason (Table 10). (84). Table 10 Distribution (in per cent) of persons on disability pensions due to musculoskeletal and connective tissue disorders by diagnosis and gender. Norway 31.12.1997. Diagnosis Low back disorders Rheumatoid arthritis Osteoarthritis Muscle pain/fibromyalgia Other musculoskeletal disorders Sum Men Women Total N=26 623 N=54 034 N=80 657 59 36 44 6 10 9 13 12 12 7 24 18 15 18 17 100 100 100
Utilisation of health care services Patients with musculoskeletal complaints are frequent visitors to primary health care centres, hospitals, and paramedical institutions (e.g. physiotherapy and chiropractic). In the Ontario Health Survey, musculoskeletal complaints caused almost 20% of all health care utilization (85). The associated health care costs that are generated by these musculoskeletal conditions are great. In 1994, musculoskeletal conditions were the second largest diagnostic group after mental retardation to generate healthcare costs in the Netherlands (86).
24
2007-2008 EULAR
The total direct cost for health services due to musculoskeletal conditions was 0.7% of the gross national product. In studies from Canada and the US, musculoskeletal conditions were calculated to generate direct health care costs that corresponded to 1.0% and 1.2% of the respective gross national products (87;88). In addition to these direct health care costs that include institution care, out-patient treatment and drug use, disability also generates considerable indirect costs, such as lost productivity and wage loss. These indirect costs of musculoskeletal conditions are much greater than the direct costs, corresponding to 2.4% and 1.3% of the gross national products in Canada and the US.
FUTURE TRENDS The impact on the individual and society is predicted to increase dramatically. Many of these conditions are more prevalent or have a greater impact in older age and by 2025 a doubling of the worlds population over 65 years is predicted, predominantly in less developed countries The number of those affected by these conditions will increase markedly, in particular those affected by osteoporosis and osteoarthritis. The percentage of over 65 years will get closer to that in more developed countries it is estimated that almost 25% of the UK population will be over 65 years by 2036. Osteoporotic hip fractures are predicted to exceed 6 million globally by 2050, with some 75% occurring in the less developed world. Changes in lifestyle factors such as obesity and lack of physical activity will also increase the burden. This great and increasing impact of musculoskeletal conditions is now recognized by the United Nations, the World Health Organisation, World Bank and governments throughout the world, through support of the Bone and Joint Decade 2000-2010 initiative. The United Nations Secretary-General Kofi Annan, when he endorsed the Bone and Joint Decade 2000-2010, emphasized that now is the time to act.
SUMMARY Musculoskeletal problems and conditions are common and their impact is pervasive Musculoskeletal problems are characterized by pain and disability There are a wide range of specific conditions that can cause musculoskeletal problems Measurement of burden requires case definitions to determine incidence and prevalence; data on impact on the individual in terms of function and structure, activities and participation, and mortality; data on impact on society and knowledge of the natural history of the various conditions The WHO international Classification of Functioning, Disability and Health provides a good model to understand the burden on the individual Summary measures of health such as the DALY are used to measure the burden on populations The major musculoskeletal conditions are osteoarthritis, rheumatoid arthritis, osteoporosis and low back pain. The burden of each of these are considered. The societal impact of musculoskeletal conditions is important when setting priorities and policies. The impact of musculoskeletal conditions on the individual and society ids predicted to increase dramatically with the ageing of the population and changes in risk factors such as obesity and physical inactivity.
ACKNOWLEDGEMENTS We wish to thank the WHO for allowing us to reproduce material from Woolf AD, Pfleger B. Burden of Musculoskeletal Conditions. Bulletin of the World Health Organisation 2003; 81: 646-56
25
2007-2008 EULAR
REFERENCES
(1) WHO International Classification of Functioning, Disability and Health available at URL: http://www3.who.int/icf/icftemplate.cfm. WHO ICF Database . 2007. (2) The Burden of Musculoskeletal Diseases at the Start of the New Millenium. Report of a WHO Scientific Group. TRS 919. Available at URL : http://whqlibdoc.who.int/trs/WHO_TRS_919.pdf. 919. 2003. Geneva, Switzerland, World Health Organization. WHO Technical Report Series. (3) The Global Burden of Disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 (Global Burden of Disease and Injury Series, Vol.1). Murrary CJL, Lopez AD, editors. 1996. Cambridge M.A., USA, Harvard University Press. (4) Global health statistics: a compendium of incidence, prevalence and Mortality estimats for over 200 conditions. (Global Burden of Disease and Injury Series, Vol.2). Cambridge: Harvard University Press, 1996. (5) The World Health Report 2000: health systems: improving performance. 2000. World Health Organization, Geneva. (6) Kazis LE, Meenan RF, Anderson JJ. Pain in the rheumatic diseases. Investigation of a key health status component. Arthritis Rheum 1983; 26(8):1017-1022. (7) Uhlig T, Hagen KB, Kvien TK. Why do patients with chronic musculoskeletal disorders consult their primary care physicians?. Curr Opin Rheumatol 2002; 14(2):104-108. (8) Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain 1984; 18(3):299-314. (9) van Baar ME, Dekker J, Lemmens JA, Oostendorp RA, Bijlsma JW. Pain and disability in patients with osteoarthritis of hip or knee: the relationship with articular, kinesiological, and psychological characteristics. J Rheumatol 1998; 25(1):125-133. (10) Health, United States, 2005. With Chartbook on Trends in the Health of Americans. Available at URL: http://www.cdc.gov/nchs/data/hus/hus05.pdf. 2005. (11) Badley EM, Ibanez D. Socioeconomic risk factors and musculoskeletal disability. J Rheumatol 1994; 21(3):515-522. (12) Reynolds DL, Chambers LW, Badley EM, Bennett KJ, Goldsmith CH, Jamieson E et al. Physical disability among Canadians reporting musculoskeletal diseases. J Rheumatol 1992; 19(7):1020-1030. (13) National Board on Health and Welfare (Sweden). Yearbook of Health and Medical Care 2001. 2001. (14) Jacobson L, Lindgren B. Vad kostar sjukdomarna? (What are the costs of illness?). 1996. Stockholm, Socialstyrelsen (National Board of Health and Welfare).
26
2007-2008 EULAR
(15) Kellgren JH, Lawrence JS. Osteoarthritis and disk degeneration in an urban population. Annals of 1958 1958; 17:388-397. (16) Spector TD, Hart DJ, Leedham-Green M. The prevalence of knee and hand osteoarthritis (OA) in the general population using idfferent clinical criteria: The Chingford Study. Arthritis Rheum 34, S171. 1991. (17) Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 1986; 29(8):1039-1049. (18) Silman AJ, Hochberg MC. Epidemiology of the rheumatic diseases. Oxford: Oxford University Press, 1993. (19) Anderson JJ, Felson DT. Factors associated with osteoarthritis of the knee in the first national Health and Nutrition Examination Survey (HANES I). Evidence for an association with overweight, race, and physical demands of work. Am J Epidemiol 1988; 128(1):179-189. (20) Tepper S, Hochberg MC. Factors associated with hip osteoarthritis: data from the First National Health and Nutrition Examination Survey (NHANES-I). Am J Epidemiol 1993; 137(10):1081-1088.
(21) Bremner JM, Lawrence JS, Miall WE. Degenerative joint disease in a Jamaican rural population. Ann Rheum Dis 1968; 27(4):326-332. (22) Solomon L, Beighton P, Lawrence JS. Rheumatic disorders in the South African Negro. Part II. Osteo- arthrosis. S Afr Med J 1975; 49(42):1737-1740. (23) Solomon L, Robin G, Valkenburg HA. Rheumatoid arthritis in an urban South African Negro population. Ann Rheum Dis 1975; 34(2):128-135. (24) Hoaglund FT, Yau AC, Wong WL. Osteoarthritis of the hip and other joints in southern Chinese in Hong Kong. J Bone Joint Surg Am 1973; 55(3):545-557. (25) Lawrence RC, Hochberg MC, Kelsey JL, McDuffie FC, Medsger TA, Jr., Felts WR et al. Estimates of the prevalence of selected arthritic and musculoskeletal diseases in the United States. J Rheumatol 1989; 16(4):427-441. (26) van Saase JL, van Romunde LK, Cats A, Vandenbroucke JP, Valkenburg HA. Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations. Ann Rheum Dis 1989; 48(4):271-280. (27) Valkenburg HA. Clinical versus radiological osteoarathritis in the generalpopulation. In: Peyron JG, editor. Epidemiology of osteoarthritis. Paris: Ciba-Geigy, 1980: 53-58. (28) Symmons D, Mathers C, Pfleger B. Global Burden of Osteoarthritis in the Year 2000. Available at URL: http://www.who.int/healthinfo/statistics/bod_osteoarthritis.pdf. World Health Organization, Geneva . 2003.
27
2007-2008 EULAR
(29) Danielsson L, Lindberg H. Prevalence of coxarthrosis in an urban population during four decades. Clin Orthop 1997;(342):106-110. (30) Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization. Arthritis Rheum 1995; 38(8):1134-1141. (31) Woolf AD. Healthcare services for those with musculoskeletal conditions: a rheumatology service. Recommendations of the European Union of Medical Specialists Section of Rheumatology/European Board of Rheumatology 2006. Ann Rheum Dis 2007; 66(3):293-301. (32) Woolf AD. What healthcare services do people with musculoskeletal conditions need? The role of rheumatology. Ann Rheum Dis 2007; 66(3):281-282. (33) Davis MA, Neuhaus JM, Ettinger WH, Mueller WH. Body fat distribution and osteoarthritis. Am J Epidemiol 1990; 132(4):701-707. (34) Felson DT. Does excess weight cause osteoarthritis and, if so, why? Ann Rheum Dis 1996; 55(9):668-670. (35) Petersson IF, Jacobsson LT. Osteoarthritis of the peripheral joints. Best Pract Res Clin Rheumatol 2002; 16(5):741-760. (36) Croft P, Coggon D, Cruddas M, Cooper C. Osteoarthritis of the hip: an occupational disease in farmers. BMJ 1992; 304(6837):1269-1272. (37) Symmons D. Musculoskeletal disorders (draft chapter). The Burden of Disease Global and Regional Estimates for 1990. 1996. (38) Kallman DA, Wigley FM, Scott WW, Jr., Hochberg MC, Tobin JD. The longitudinal course of hand osteoarthritis in a male population. Arthritis Rheum 1990; 33(9):1323-1332. (39) Dougados M, Gueguen A, Nguyen M, Thiesce A, Listrat V, Jacob L et al. Longitudinal radiologic evaluation of osteoarthritis of the knee. J Rheumatol 1992; 19(3):378-384. (40) DANIELSSON LG. INCIDENCE AND PROGNOSIS OF COXARTHROSIS. Acta Orthop Scand 1964; 42:SUPPL-114. (41) World Health Report 2001. Mental Health: New Understanding, New Hope. World Health Organization, editor. 2001. Geneva. (42) Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31(3):315-324. (43) Linos A, Worthington JW, O'Fallon WM, Kurland LT. The epidemiology of rheumatoid arthritis in Rochester, Minnesota: a study of incidence, prevalence, and mortality. Am J Epidemiol 1980; 111(1):87-98. (44) Abdel-Nasser AM, Rasker JJ, Valkenburg HA. Epidemiological and clinical aspects relating to the variability of rheumatoid arthritis. Semin Arthritis Rheum 1997; 27(2):123-140.
28
2007-2008 EULAR
(45) Del Puente A, Knowler WC, Pettitt DJ, Bennett PH. High incidence and prevalence of rheumatoid arthritis in Pima Indians. Am J Epidemiol 1989; 129(6):1170-1178. (46) Symmons D, Mathers C, Pfleger B. The global burden of rheumatoid arthritis in the Year 2000. Available at URL: http://www.who.int/healthinfo/statistics/bod_rheumatoidarthritis.pdf. 2003. (47) Weyand CM, Hicok KC, Conn DL, Goronzy JJ. The influence of HLA-DRB1 genes on disease severity in rheumatoid arthritis. Ann Intern Med 1992; 117(10):801-806. (48) Symmons D, Harrison B. Early inflammatory polyarthritis: results from the norfolk arthritis register with a review of the literature. I. Risk factors for the development of inflammatory polyarthritis and rheumatoid arthritis. Rheumatology (Oxford) 2000; 39(8):835-843. (49) Ollier WE, Harrison B, Symmons D. What is the natural history of rheumatoid arthritis? Best Pract Res Clin Rheumatol 2001; 15(1):27-48. (50) Hakala M, Nieminen P, Koivisto O. More evidence from a community based series of better outcome in rheumatoid arthritis. Data on the effect of multidisciplinary care on the retention of functional ability. J Rheumatol 1994; 21(8):1432-1437. (51) Hochberg MC, Chang RW, Dwosh I, Lindsey S, Pincus T, Wolfe F. The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis. Arthritis Rheum 1992; 35(5):498-502. (52) Brooks PM. MJA Practice Essentials - Rheumatology. Sydney: Australasian Medical Publishing Company Limited, 1997. (53) Darmawan J, Muirden KD, Valkenburg HA, Wigley RD. The epidemiology of rheumatoid arthritis in Indonesia. Br J Rheumatol 1993; 32(7):537-540. (54) Spector TD, Hart DJ, Powell RJ. Prevalence of rheumatoid arthritis and rheumatoid factor in women: evidence for a secular decline. Ann Rheum Dis 1993; 52(4):254-257. (55) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: report of a World Health Organization Study Group. WHO Technical Report Series No. 843. WHO Technical Report Series No. 843. 1994. Geneva, World Health Organization. (56) Oleksik A, Lips P, Dawson A, Minshall ME, Shen W, Cooper C et al. Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures. J Bone Miner Res 2000; 15(7):1384-1392. (57) van Staa TP, Dennison EM, Leufkens HG, Cooper C. Epidemiology of fractures in England and Wales. Bone 2001; 29(6):517-522. (58) Cooper C, Melton LJ, III. Epidemiology of osteoporosis. Trends Endocrinol Metab 1992; 314:224-229. (59) Melton LJ, III. Epidemiology of fractures. In: Riggs BL, Melton LJ, III, editors. Osteoporosis: Etiology, Diagnosis, and Management. Lippincott-Raven Publishers, 1995: 225-47.
29
2007-2008 EULAR
(60) O'Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int 2001; 12(7):555-558. (61) The European Prospective Osteoporosis Study Group. Incidence of vertebral fractures in Europe: results from the European prospective osteoporosis study (EPOS). J Bone Miner Res 2002; 17:716-724. (62) Kanis JA, Johnell O, Oden A, Jonsson B, De Laet C, Dawson A. Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000; 27(5):585-590. (63) Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 1995; 332(12):767-773. (64) Kanis JA, Johnell O, Oden A, De Laet C, Jonsson B, Dawson A. Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone 2002; 30(1):251-258. (65) Melton LJ, III. Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 2003; 18(6):1139-1141. (66) Sernbo I, Johnell O. Consequences of a hip fracture: a prospective study over 1 year. Osteoporos Int 1993; 3(3):148-153. (67) Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol 1990; 45(3):M101-M107. (68) Kaukonen JP, Karaharju EO, Porras M, Luthje P, Jakobsson A. Functional recovery after fractures of the distal forearm. Analysis of radiographic and other factors affecting the outcome. Ann Chir Gynaecol 1988; 77(1):27-31. (69) Cooper C. The crippling consequences of fractures and their impact on quality of life. Am J Med 1997; 103(2A):12S-17S. (70) Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 1999; 353(9156):878-882. (71) Cooper C, Atkinson EJ, Jacobsen SJ, O'Fallon WM, Melton LJ, III. Population-based study of survival after osteoporotic fractures. Am J Epidemiol 1993; 137(9):1001-1005. (72) Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C et al. Mortality after osteoporotic fractures. Osteoporos Int 2004; 15(1):38-42. (73) Cooper C, Campion G, Melton LJ, III. Hip fractures in the elderly: a world-wide projection. Osteoporos Int 1992; 2(6):285-289. (74) Anderson JA. Epidemiological aspects of back pain. J Soc Occup Med 1986; 36(3):90-94. (75) Frymoyer JW. Back pain and sciatica. N Engl J Med 1988; 318(5):291-300.
30
2007-2008 EULAR
(76) Van den Velden J, De Bakker DH, Claessens AAMC, et al. Een Nationale Studie Naar Ziekten en Verrichtingen in de Huisartspraktijk. 1991. Utrecht, NIVEL. Basisrapport: Morbiditeit in de huisartspraktijk. (77) Andersson GB. Epidemiological features of chronic low-back pain. Lancet 1999; 354(9178):581-585. (78) Palmer KT, Walsh K, Bendall H, Cooper C, Coggon D. Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years. BMJ 2000; 320(7249):1577-1578. (79) Tellnes G, Svendsen KO, Bruusgaard D, Bjerkedal T. Incidence of sickness certification. Proposal for use as a health status indicator. Scand J Prim Health Care 1989; 7(2):111-117. (80) Szubert Z, Sobala W, Zycinska Z. [The effect of system restructuring on absenteeism due to sickness in the work place. I. Sickness absenteeism during the period 19989-1994]. Med Pr 1997; 48(5):543-551. (81) Kelsey J. Back pain. Fictional 1982. (82) Stansfeld SA, North FM, White I, Marmot MG. Work characteristics and psychiatric disorder in civil servants in London. J Epidemiol Community Health 1995; 49(1):48-53. (83) Brage S, Nygard JF, Tellnes G. The gender gap in musculoskeletal-related long-term sickness absence in Norway. Scand J Soc Med 1998; 26(1):34-43. (84) National Insurance Administration. 1998. (85) Badley EM, Rasooly I, Webster GK. Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability, and health care utilization: findings from the 1990 Ontario Health Survey. J Rheumatol 1994; 21(3):505-514. (86) Meerding WJ, Bonneux L, Polder JJ, Koopmanschap MA, van der Maas PJ. Demographic and epidemiological determinants of healthcare costs in Netherlands: cost of illness study. BMJ 1998; 317(7151):111-115. (87) Coyte PC, Asche CV, Croxford R, Chan B. The economic cost of musculoskeletal disorders in Canada. Arthritis Care Res 1998; 11(5):315-325. (88) Yelin E, Callahan LF. The economic cost and social and psychological impact of musculoskeletal conditions. National Arthritis Data Work Groups. Arthritis Rheum 1995; 38(10):1351-1362.
31
2007-2008 EULAR

Impact of Musculoskeletal Conditions

Transféré par

Informations du document

Description originale:

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Impact of Musculoskeletal Conditions

Transféré par

Droits d'auteur :

Formats disponibles

Eular On-line Course on Rheumatic Diseases module n3 Anthony D Woolf, Bruce Pfleger, Stefan Bergman

CLINICAL EPIDEMIOLOGY IMPACT OF MUSCULOSKELETAL CONDITIONS

Hip Hand Progression Knee

Vitamin D Smoking (protective) Alignment

Quadriceps strength (protective) Intensive sport activities

High body mass index Intensive sport activities

Health state descriptions for osteoarthritis

Osteoarthritis of the knee Grade 2 symptomatic

Osteoarthritis of the knee Grade 3-4 symptomatic

Balance, gait or mobility problems

Impaired cognition or depression Blackouts

Epidemiology of fractures in England and Wales (57)

Hospital or insurer activity data of visits

Other disease related costs

Change of living status

Out of pocket Intangible costs

Vous aimerez peut-être aussi