A Time for Action: Opportunities for Preventing the
Growing Burden and Disability from Musculoskeletal
Conditions in Low- and Middle-Income CountriesThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Best Pract Res Clin Rheumatol. 2014 (Jun); 28 (3): 377–393 ~ FULL TEXT
Damian Hoy, Jo-Anne Geere, Fereydoun Davatchi, Belinda Meggitt, Lope H. Barrero
University of Queensland,
School of Population Health,
Brisbane, Australia;
Secretariat of the Pacific Community,
Public Health Division,
New Caledonia.
damehoy@yahoo.com.au
Musculoskeletal (MSK) conditions cause an enormous global burden, and this is dramatically increasing in developing countries, particularly due to rapidly ageing populations and increasing obesity. Many of the global non-communicable disease (NCD) initiatives need to expand beyond the traditional 'top four' NCD groups by incorporating MSK diseases. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. A better inclusion of MSK conditions will avoid doubling of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Other key opportunities for action include the following: ensuring the principles of 'development effectiveness' are met; strengthening leadership and commitment; building the research, information and evidence base; and reducing the incidence and disability of MSK conditions through better prevention. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.
KEYWORDS: Musculoskeletal, Rheumatology, Burden, Disability, Low income, Middle income, Developing, Prevention
From the FULL TEXT Article:
Introduction
Musculoskeletal (MSK) conditions cause an enormous global burden [1–10]. Of the 291 conditions included in the Global Burden of Disease (GBD) 2010 study, low back pain (LBP) ranked the highest in terms of disability and sixth in terms of overall burden, while neck pain (NP) ranked the fourth highest for disability and 21st for burden. Osteoarthritis (OA), rheumatoid arthritis (RA) and gout were also significant contributors to the global disability burden. The burden from MSK conditions will become an increasingly important issue for health systems as the number of people experiencing disabilities rises [1]. This is particularly relevant in low- and middle-income countries (developing countries) due to rapidly ageing populations and increasing obesity, which are two of the major risk factors for MSK conditions [1–12].
While the evidence base has increased in developing countries over the recent years, there are still major gaps in our understanding of the prevalence of MSK conditions, and even less is known about the predictors, outcomes and potentially effective approaches to the primary, secondary and tertiary prevention of MSK conditions in this context. Various challenges in relation to reducing the burden of MSK in developing countries have been highlighted over the recent years. These include underfunded health care [13] and related research [14]; insufficient number of health-care professionals trained to treat MSK conditions appropriately [15, 16], and consequently inappropriate or delayed treatment when health care is available [15]; lack of understanding of the magnitude of the problem [16, 17]; and lack of clinical guidelines suitable for developing countries [18]. Additional challenges stem from barriers to accessing health care [16, 19], especially among vulnerable populations such as low socioeconomic groups and immigrants [20, 21].
This chapter describes what is known about these issues and presents a multi-tiered approach to dealing with the growing burden from MSK problems in developing countries (Fig. 1). This includes ensuring the principles of ‘development effectiveness’ are met; strengthening leadership and commitment; seeing the meaningful inclusion of MSK conditions in global and regional policy and programmes; building the research, information and evidence base, including the collection, analysis and use of quality data; reducing the incidence of MSK conditions through better prevention; and reducing disability from MSK conditions through better management. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.
Acknowledge the current and future problem
What we know now e the current burden from MSK conditions in developing countries Burden of Disease (BoD) studies describe the burden arising from specific diseases, injuries or risk factors, using a summary measure called disability-adjusted life years (DALYs) [22]. BoD research takes both fatal and non-fatal health outcomes into account, and it is thus a far more comprehensive measurement framework for assessing disease burden than simply relying on mortality or prevalence alone [23]. DALYs are calculated by adding years of life lost in a population due to premature mortality (YLL) to healthy years of life lost in a population due to disability (YLD). The most recent BoD study, GBD 2010, was conducted over 5 years from 2007 to 2012 and involved collaboration between universities and experts in epidemiology and other areas of public health research from around the world. Disease burden was calculated for 291 causes in the 21 GBD world regions for the years 1990, 2005 and 2010 [1].
GBD 2010 revealed that 40% of the burden in developing countries is due to communicable diseases, 49% to non-communicable diseases (NCDs) and 11% to injuries. Table 1 shows the top 10 causes of burden from NCDs in developing countries. Three of the top 10 conditions in terms of both burden and disability were MSK conditions. Most notably, LBP caused the highest disability and the fourth highest burden of all the NCDs in the developing countries. In terms of broad cause groups, cardiovascular and circulatory diseases cause the greatest NCD burden in developing countries (214 million DALYs), followed by mental and behavioural disorders (141 million); cancers (130 million); MSK diseases (119 million); chronic respiratory diseases (101 million); diabetes and urogenital, blood and endocrine diseases (99 million); neurological disorders (57 million); digestive disorders (except cirrhosis) (27 million); and cirrhosis of the liver (25 million).
MSK conditions were found to account for an enormous 19.2% of all disability (YLDs) in developing countries in 2010 and this increased from 16.8% in 1990. Again, this increase was largely due to population growth and ageing. In terms of broad cause groups, mental and behavioural disorders and MSK diseases cause by far the greatest NCD disability in developing countries (137 million and 116 million DALYs, respectively). This is followed by diabetes and urogenital, blood and endocrine diseases (42 million); chronic respiratory diseases (40 million); neurological disorders (32 million); cardiovascular and circulatory diseases (14 million); digestive disorders (except cirrhosis) (four million); cancers (two million); and cirrhosis of the liver (0.5 million).
It should be noted that some MSK conditions are classified under alternative categories in BoD. For example, carpal tunnel syndrome is classified under the neurological category, and injuries related to motor crashes and any fall-related MSK injury, fracture, sprain or strain (other than hip fracture) are classified under the injury category. This means that the full burden from MSKs is underestimated by GBD 2010. In addition, it is worth noting that in BoD research, the definition of disability is health loss resulting from episodes of disease and injury, often resulting in impairments of body structures and functions, as well as more complex human operations (e.g., mobility). Broader constructs of the magnitude of diseases such as participation restriction, well-being, carer burden, increased pressure on health-care systems and economic cost are not included. It is prudent to also consider these broader constructs when examining the impact of disease on populations. For MSK conditions, these are substantial. [1, 24, 25].
Of the 291 conditions studied in GBD 2010, LBP ranked 10th in developing countries in terms of burden and first in terms of disability. NP, OA, RA and other MSK conditions also ranked highly (Table 2). As LBP, NP, OA and gout do not involve mortality, DALYs equate to YLDs for these conditions. LBP DALYs/YLDs were higher in males (32.3 million) than in females (26.1 million), with the raw number highest in the 35–45-year age group, and the age-standardised rate highest in the 75 + age group. DALYs/YLDs for NP were higher in females (13.3 million) compared with males (10.7 million); the rawnumber was also highest in the 35–45-year age group, although the age-standardised ratewas highest in the 45–55-year age group. For OA, DALYs/YLDs were also higher in females (7.8 million) compared with males (4.6 million), with the raw number of DALYs/YLDs highest in the 50–60-year age group, and the rate highest in the 75 + age group. Gout was highest in males (36,000 DALYs/YLDs) compared with females (10,000 DALYs/YLDs); the raw number was also highest in the 50–60-year age group, and the age-standardised rate highest in the 75 + age group. Females also had higher DALYs and YLDs for RA in developing countries compared with males (2.1 million DALYs vs. 0.8 million, respectively; and 1.7 million YLDs vs. 0.4 million, respectively). For all MSK conditions, the raw number of DALYs was highest in the 50–60-year age group, and the rate highest in the 75 + age group, while the raw number of YLDs was highest in the 35–45-year age group, and the rate highest in the 75 + age group.
What will happen e the future burden from MSK conditions in developing countries
From 1990 to 2010, the burden in developing countries attributable to MSK conditions increased 60% (Table 3). This increase in DALYs was relatively consistent across MSK conditions, and was due to population growth and ageing [1–7, 9, 10]. A cause for great concern is that population growth, ageing and other risk factors for the burden of MSK conditions will increase dramatically in developing countries over the coming decades.
Age is one of the most common risk factors for MSKs [26], and the greatest effects of population ageing are predicted in developing countries [27]. By 2050, it is predicted there will be five times as many people over 40 years living in these countries compared to wealthier countries, with an estimated 3.53 billion people 40 years or older in developing countries compared to 645 million people in high-income countries [27]. In most of the developed world, demographic change occurred gradually, following steady socio-economic growth over several decades [25]. However, in many developing countries, this change is being compressed into two or three decades, and health systems and national economies are ill-equipped to deal with this.
Many of the risk factors associated with MSKs in high-income countries are currently present in developing countries, including obesity, increased motorisation and work-related issues [26, 28]. Obesity is expected to rise dramatically in the developing world over the coming two decades [29]. Increased levels of motorisation are resulting in larger numbers of motor accidents [30], escalating the incidence of whiplash-associated disorders and other motor vehicular-related trauma. An estimated 80e90% of the population in developing countries are involved in ‘heavy work’ [31];work demands are extensive in subsistence communities; and activities such as the collection of water and farming have been shown to increase the risk of LBP [32, 33]. In urban areas, there is rapid industrial growth and the prevalence of occupational MSK conditions is already very common [34]. As a consequence of these factors, the number of people experiencing MSKs in developing countries will increase dramatically over the coming decades, and this will result in an exponential increase in the burden from MSKs in these countries.
The impact from the increasing MSK burden in developing countries is likely to be extreme. Health promotion and treatment services do not receive the resourcing seen in high-income countries, and health insurance and social security frequently do not exist. Further to this, a large proportion of those affected are in the most productive years of life when functioning is often a necessity to support both younger and older family members.
The findings from GBD 2010 have major implications regarding health system investment decisions. Due to the current and future epidemiological pattern and associated costs of MSK conditions, health systems need to develop coherent policies for dealing with this burden [1]. Extending retirement age is a proposed strategy to deal with the resource burden of the ageing global population; however, the substantial MSK burden in this ageing population will markedly diminish the capacity to implement this strategy successfully [25]. Further, many health systems are already struggling with the challenges resulting from the epidemiological transition and the consequent burden from NCDs. Health system investments will support future decades, and, thus, in addition to health human resources and training, they need to reflect future burden. The pace of the demographic and epidemiological change in developing countries is such that a forward-looking assessment of future disease burden is critical, while research to assess the most effective and affordable strategies for preventing and managing the burden from MSKs is urgently needed.
Opportunities for action
Taking a development effectiveness approach
International agreements on development effectiveness have stressed the importance of applying lessons that have been learnt in international development [35–37]. The key principles from these agreements, as outlined below, contribute to higher-quality and more effective development cooperation [35].
Community ownership and inclusive development partnerships
A key focus of research and interventions should be local participation, ownership, integration and coordination [38]. Inclusion and empowerment of local communities is vital at every stage of a development initiative programme. Planning and decision-making processes should be locally owned, and extensive community consultation should take place to facilitate this ownership. Trusting relationships are an important ingredient for promoting honest communication and designing and implementing effective programmes.
Alignment
Any MSK initiative needs to be integrated with existing priorities and policies set out by developing countries, for example, national health or development strategies [35]. This includes indicators for monitoring and evaluating the performance of initiatives [35]. Consulting and collaborating broadly with government and non-government bodies will assist aligning new programme endeavours to existing initiatives where this is feasible. This will promote a more integrated programme, help avoid duplication, improve participation and commitment and provide opportunities to share resources [37–39].
Harmonising and mainstreaming
MSK initiatives should not be seen as a vertical programme, but rather one that expands across the entire health system and beyond. MSK initiatives, wherever possible, should be conducted through existing national and regional systems and processes. It is important to ensure that existing systems are not ignored, but rather built upon and strengthened. Much of the expertise required for responding to the burden of MSK conditions is often available at the local level and should be utilised from this level wherever possible. Technical assistance should always ensure that local capacity is being built.
Delivering results and mutual accountability
Advocacy and resource mobilisation are critical, and research, evidence and information have the power to demonstrate to policymakers and donors the true impact from MSKs and thus encourage adequate resourcing. Accountable and transparent planning and financial management systems are needed. Development partners and countries need to have mutual accountability, responsibility and agreed monitoring and evaluation mechanisms.
Leadership and commitment
A well-established need for the success of any initiative is competent, engaged and enthusiastic leadership. To achieve this level of leadership, leaders need to understand the extent of the burden of MSKs and must be able to identify risk factors that can be targeted in health policy and practice [40]. Information on MSK burden and risk factors needs to be presented to leaders in a way that engages them and helps them understand the consequences of ignoring MSKs and, conversely, convinces them of the positive impacts of reducing the burden of MSK. This information can then be used to guide the development and implementation of policies and legislation aimed at prevention, and to inform resource allocation for treatment and rehabilitation of MSK disorders [40].
Meaningful inclusion in global and regional policy and programmesNeed for greater focus on NCDs Governments and other donors to aid programmes have traditionally placed the bulk of their funds towards programmes addressing high-mortality communicable diseases. In the last two decades, there has been increasing recognition of the contribution of NCDs to the overall global burden of disease in developing countries. However, despite the fact that NCDs cause more burden in developing countries than communicable diseases [1], there continues to be systematic underfunding of NCD programmes [41]. From 2001 to 2008, <3% of development assistance health expenditurewas spent on NCDs. In 2007, this equated to $503 million out of $22 billion spent on health. In the same year, donors spent $0.78/DALYon NCDs in developing countries, compared to $23.9/ DALY on human immunodeficiency syndrome (HIV), tuberculosis (TB) and malaria [42]. While investments in health and development have seen substantial reductions in the burden from communicable diseases, it is now critical that international agencies and donors have a major shift in the direction of their funding. This is even more urgent given the dramatically increasing burden from
NCDs and MSKs in developing countries, and the potential for health systems in developing countries to be ill-prepared for this future burden.
Need for the inclusion of MSK conditions in global and regional NCD policy and programmes There is an urgent need for the World Health Organization (WHO) and other agencies to expand beyond the traditional ‘top four’ NCD groups by incorporating MSK diseases, in addition to mental and behavioural disorders, in their policies and programmes. Currently, for example, the United Nations (UN) Summit on NCDs in 2011 was limited to cancers, cardiovascular diseases, chronic respiratory diseases and diabetes [43]; the Non-Communicable Diseases Alliance [44] limits its focus to these four groups, while the Global Alliance for Chronic Diseases [45] advocates for action on these four groups, but also includes mental health. The WHO STEPwise surveillance programme, which measures and monitors the prevalence of chronic disease risk factors in developing countries [46], limits its main focus to these four groups, but has also recently added optional modules for mental health, oral health, violence and injuries.
Thus, while mental health is starting to see greater inclusion in some of these global initiatives, MSK is not. In failing to include MSK conditions and mental and behavioural disorders, initiatives ignore 26% of the burden from NCDs in developing countries. This will result in significant direct and indirect costs to the health system and individuals affected, and will in turn critically overwhelm these already strained systems [1–10, 47, 48]. Table 4 demonstrates the value of inclusion of MSK diseases, along with mental and behavioural disorders. It is also important to note that many people with these traditional ‘top four’ NCDs also have MSK conditions, and the intervention programmes such as increasing physical activity will not be able to be achieved if the MSK conditions are also not addressed.
One MSK initiative, the Community Oriented Program for Control Of Rheumatic Diseases (COPCORD), is a collaboration between the WHO and the International League of Associations for Rheumatology (ILAR), and aims to recognise, prevent and control MSKs in developing countries [49]. While substantial work has been done in gathering information on the epidemiology of MSKs, the lack of resourcing has meant that research has been limited to selected communities. International NCD initiatives need to build on the valuable work of COPCORD and also facilitate the better inclusion of MSK research and surveillance. This will encourage a more efficient, harmonised and streamlined approach to addressing the prevention and control of all NCDs, including MSKs, particularly as they share modifiable risk factors, such as obesity, with the other four NCD groups. The inclusion of MSKs also has the potential to enable MSK estimates to be more nationally representative and to reduce the burden that multiple studies have on local communities.
Need to avoid a vertical approach to MSK prevention and management Developing countries cannot afford the luxury of disease-specific prevention and management policies and programmes. Increasingly, there is a move away from fragmented ‘vertical’ condition- specific disease programmes (e.g., a programme solely focussed on malaria in children) towards more integrated health system-strengthening approaches (e.g., the integrated management of childhood illness e IMCI) [50]. Lessons have been learnt over the past decades of the detrimental consequences on health systems in developing countries that taking a vertical, disease-specific approach can have. Cassels and Janovsky have highlighted a number of the pitfalls of vertical condition-specific programmes, including fragmentation and duplication, and competition from projects (e.g., from nongovernment and international organisations) for national staff, affecting their ability to perform their usual duties within the health system [39]. Disease-specific programmes can weaken alreadycompromised health systems and result in other areas being neglected [51]. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone.
Opportunities and benefits of better inclusion of MSK conditions in global and regional NCD policy and programmes
For the above reasons, the opportunities for collaboration in the prevention and management of MSK conditions within the health sector, and also between sectors, must be explored and encouraged. A better inclusion of MSK conditions will avoid duplication of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. For example, physical activity can help to prevent cardiovascular disease, colon and breast cancers, type 2 diabetes and osteoporosis [52]. It can also help to prevent disabling OA and LBP [53, 54]. Collaboration between groups working on these diseases can result in strategies to improve physical activity, reduce resource wastage and ensure consistent public health messages are provided. Many other opportunities exist to streamline with initiatives currently addressing the burden from other NCDs in developing countries. This could result in significantly reducing the burden of MSK conditions, catalysing the reduction in burden of these other NCDs, and in strengthening health systems generally.
Harnessing research, information and evidenceAddressing research gaps The 2013 WHO World Health Report states that ensuring “everyone has access to quality health services that they need without risking financial hardship from paying for them requires a strong, efficient, well-run health system; access to essential medicines and technologies; and sufficient, motivated health workers. The challenge for most countries is how to expand health services to meet growing needs with limited resources.” [55] Approaches to the inclusion of MSK conditions, including those mentioned above, need to be creative and cost-efficient given these limited resources. WHOpoint out that “there are many unsolved questions on how to provide access to health services and financial risk protection to all people in all settings, and that currently, most research is invested in new technologies rather than in making better use of existing knowledge. Much more research is needed to turn existing knowledge into practical applications.” [55] This is pertinent for MSK conditions as one of the greatest research needs is how to best reduce the burden of MSK conditions in away that is affordable and effective and builds on existing health systems rather than creating stand-alone structures. Despite the enormous estimated burden from MSK conditions in developing countries, relatively little is published on these conditions from these countries. Studies included in GBD 2010 were primarily descriptive epidemiological studies on prevalence, incidence and, where available, duration and remission. Further research is needed to improve understanding of the occurrence, impact, risk factors and potential interventions for MSK conditions [1–10, 32], and of effective ways for policy change in developing countries.
Understanding howto apply what is already known may be especially challenging in countries with weak institutions and lack of transparent decision-making processes. These can lead to widespread inefficiency that affects competitiveness and the capacity to grow [56], and ultimately undermines the socio-economic conditions and thus the health of the population. There is also a clear need for further research on the natural history of MSKs. Long-term longitudinal studies that include people from the general population would provide important information on the average duration and severity of disability from MSKs. Incorporating this research with pain diaries to track the daily patterns of pain and disability would add greater depth to this research [1–10].
The WHO has made a number of important recommendations in the 2013 World Health Report, namely that research needs to be locally focussed and driven by local communities. While there are growing numbers of authors publishing research from developing countries, there is a need to build on this and to ensure that global and regional initiatives build local research capacity. Opportunities for collaboration between universities, governments, international organisations and the private sector should be explored. A more coordinated research effort would likely minimise duplication and the associated burden placed on local communities [55].
Strengthening monitoring, evaluation and surveillance Health systems in developing countries will need to monitor progress in endeavours to mitigate and reduce the burden of MSK conditions [47]. Morbidity from MSKs is a critical outcome indicator and vital for monitoring the burden of MSKs and impact of interventions. Specific and high-priority information needs related to MSKs include prevalence, risk factors, outcomes and potentially effective approaches to primary, secondary and tertiary prevention.
There is an urgent need to improve the reliability of national-level data to better inform and monitor action for halting the MSK burden. Early detection of disease through reliable and wellintegrated systems is essential for facilitating an early response for both communicable diseases and NCDs. Surveillance needs to be closely linked with monitoring and evaluation frameworks of national policies and programmes [57]. Initiatives should aim to develop the technical requirements for MSK monitoring, evaluation and surveillance. The key function of these initiatives should be to strengthen the availability, quality and use of MSK information, including routinely collected information, surveys and studies. Development effectiveness principles should be adhered to, including building on existing networks rather than creating duplicate mechanisms, ensuring initiatives are owned and led by the people of developing countries and ensuring efforts are well integrated with the rest of the health information system (HIS).
Fig. 2 highlights the conceptual framework for strengthening HIS. A sound HIS provides information on the policy and environmental context, risk factors, morbidity and mortality and other outcomes important for assessing the overall impact of disease. Monitoring and evaluation indicators must be closely linked with the HIS. In strengthening each of the elements of the HIS, the key considerations are to ensure there are sufficient resources; appropriate indicators; data sources and collection mechanisms; sound capacity in data storage, cleaning, analysis and interpretation; appropriate information products; and dissemination and use of the information.
Strategies for prevention
Prevention strategies can be delivered through general public health campaigns targeted towards particular populations or settings, and include health promotion targeting individuals to modify their own lifestyle behaviours and choices. Two approaches to preventing disability from MSK conditions can be considered. The first involves strategies to reduce the incidence of individuals developing MSK disorders, and the second focusses on strategies to reduce the extent of disability associated with MSK conditions. These two aspects of disability prevention are important because while some MSK disorders are preventable or can be treated effectively, others are highly prevalent, often long-term conditions that are associated with ageing or regular activities such as work and sport. Whilst the prevalence of the latter group of disorders may be difficult to change, the extent of disability associated with them can be reduced. Within both approaches, MSK risk factors common to other NCDs can be targeted and linkages with existing health programmes explored, both to maximise efficiency and to more comprehensively evaluate programme outcomes.
Reducing the incidence of MSK disorders
To prevent or reduce the incidence of MSK disorders in a particular population, it is logical to eliminate or reduce modifiable risk factors and mitigate the impact of unmodifiable risk factors that exist in that population. This requires insight into the usual work, social and cultural practices as well as the environment of communities within the population of interest, as risk factors will emerge from or be influenced by the local context.
Creating safer environments
In developing countries, accidental trauma is a major cause of MSK injury [58, 59], and most traffic fatalities and injuries affect pedestrians, passengers, cyclists and children [60]. Particularly in densely populated urban areas, the growth in numbers of vehicles and lack of safe walkways, combined with poor enforcement of traffic safety regulations, mean that affordable transport such as travelling by foot, bicycle or crowded public minibuses carries the risk of accident and injury [60]. Therefore, initiatives that improve traffic and pedestrian safety have great potential to reduce the incidence of MSK injuries and death due to motor vehicle accidents [61, 62]. For example, recent WHO guidance on strengthening legislation has included targeting key risk factors of speeding, drink driving, use of motorcycle helmets, seatbelts and child restraints [63]. The impact is likely to be greatest for poorer people, who may have little choice other than to use unsafe transport or conduct their trade in heavy traffic areas. Initiatives that aim to create safer communities by focussing on lifestyle behaviours, such as promoting responsible drinking, may also reduce the incidence of MSK injury due to motor vehicle accidents and domestic violence because of the strong association between alcohol consumption and these causes of traumatic injury [61, 64]. It is obvious that regional conflict and natural disasters can be a cause of traumatic MSK injury [65, 66], and efforts towards conflict resolution and rebuilding safer communities or protecting populations from lasting environmental hazards also has the potential to reduce the incidence of MSK injury. Disaster plans and timely provision of emergency medical aid, which includes trauma and rehabilitation specialists, has the potential to reduce the extent of acute and long-term disability associated with MSK and other injuries in conflict or disaster-affected regions [58, 67].
Working for population health
A recent systematic review of studies conducted in occupational settings [68] found that heavy workload is a risk factor for LBP. They also reported that the accumulation of loads or frequency of lifts, working in a flexed and/or rotated position, manual handling, physical exertion and vehicle driving are all moderately to strongly associated with LBP. In contrast to these findings, and with the exception of intense physical exertion and gardening or yard work, everyday physical activities in leisure time were found to be moderately to strongly associated with a decreased risk of LBP. The Bone and Joint Decade Neck Pain Task Force found that smoking, exposure to environmental tobacco and work factors such as high quantitative work demands, low social support at work and sedentary, repetitive or precision work increased the risk of NP, whilst workers who engaged in general exercise and sport, or demonstrated greater optimism or self-assurance, were more likely to experience improvement in NP [69].
In developing countries, a higher proportion of people are exposed to heavy workload and other occupational risk factors described above, whether in paid employment, or informal, subsistence or domestic work. It has been estimated that 80–90% of the population in developing countries are involved in ‘heavy work’ [31]. Work demands are extensive in subsistence communities, and studies have found that activities such as the collection of water and farming activities can increase the risk of LBP and knee pain [32, 33, 70]. Of particular note, manual labour conducted outside of formal employment contracts or during paid employment with poor adherence to occupational health and safety practice may result in people being exposed to much greater physical loading, with fewer rest periods and lesser opportunity for leisure time, than people working in higher-income or regulated employment settings [71–74]. They may be exposed to unique physical stresses, such as head loading [75], as well as greater risk of injury due to manual handling accidents or falls as a consequence of unsafe working environments and equipment, and are likely to have less workplace support [76]. Therefore, a focus on creating and promoting safer work practices, which reduce the extremes of physical loading and risk of accidents during manual handling, may need to be prioritised in developing countries. Labour organisation or fair trade initiatives that support a ‘living wage’ may play an important role in enabling people to achieve the economic independence that would allow them to adopt more health-inducing workeleisure time balance, as well as greater optimism for the future and self-assurance [77].
Supporting vulnerable individuals
The ‘healthy worker effect’ [78] may be a mechanism by which the potential impact of some risk factors for MSK disorders is underestimated in developing countries. Cohorts typically recruited to occupational studies are working-age adults healthy enough to be employed and at work, often with a greater representation of men than in the general population [79, 80]. In developing countries, informal or domestic work and household chores, which are commonly performed by children, women or the elderly, involve substantial physical loading and are associated with complaints of pain that can be reasonably attributed to MSK disorders [33, 81]. At different stages of development for young and old people, they have reduced capacity for physical loading and will be more vulnerable to MSK injury or strain than the typical cohorts recruited to occupational research in more developed countries [33]. Individuals in the poorer areas of developing countries are also more likely to be affected by longterm conditions [82] or poorer general health [83], which may further reduce their tolerance of physical loading and therefore increase their personal risk of developing MSK injury or disability. For these reasons, initiatives that aim to improve physical work practices in the informal sector or improve public health services in poorer communities could reduce the daily burden of physical work in the most vulnerable population subgroups. For example, provision of electricity and improved access to safe drinking water in remote or rural communities could substantially reduce the daily physical burden of carrying firewood and water, which often falls mainly on women and children and may be additional to other manual labour [84, 85].
Reducing the extent of disability associated with MSK conditionsImproving access to rehabilitation In many developing countries, hospitals and centres providing rehabilitation services and assistive devices that could minimise MSK disability are often poorly resourced and located in just a few regional centres [86], making services difficult to access. The physical difficulties and costs associated with travelling to or staying near rehabilitation services are particularly prohibitive for people on low incomes or living in remote or rural areas [87]. Community-based rehabilitation (CBR) has been promoted as an effective way to decentralise disability services and build the local capacity to provide or develop equipment and care that is suited to the local environment [88]. In particular, if combined effectively with better access to centralised specialist services that cannot be feasibly provided in smaller centres, CBR has great potential to reduce disability from permanent or long-term MSK conditions by connecting people with the services and equipment that they need for normal functioning and independence [89, 90].
Staying employed and enabling productive work In developing countries, loss of employment can be economically catastrophic for families and, combined with disability, can lead to escalating risks of poverty, poor health and exposure to unsafe work [87]. Even in developed countries, where considerable improvements in occupational health and safety have been achieved, disability related to common MSK conditions, such as back pain and NP, remains high and one of the major causes of lost working days and long-term unemployment [91].
Whilst safety and working conditions can be addressed to reduce the incidence of MSK conditions, much can be done to minimise work disability or loss of employment should injury or pain occur. The strategies include prompt access to a health service to distinguish serious injury or disease, which requires further investigation or medical treatment, from more simple mechanical MSK strain, which can be managed with no, or minimal, absence from work. The strategies to prevent unnecessary work disability can include modification or pacing of tasks and graduated return to usual work to accommodate symptom resolution, ergonomic assessment, advice or modifications to avoid further exacerbation of symptoms [71–73] and therapies including exercise to improve physical fitness and maintain function [92]. Many people with temporary or permanent MSK impairment benefit from an early return to work if some modification of work roles and tasks or use of assistive devices can be accommodated.
Promoting lifestyle choices to reduce MSK disability In many developing countries, the burden of infectious disease is being compounded by the longterm adverse health effects of lifestyle choices related to diet, smoking, alcohol consumption and reduced levels of physical activity [82, 93]. A result of this is rising levels of chronic conditions such as obesity, which is associated with common MSK conditions such as knee and hip arthritis, LBP and related disability [94, 95]. Joint replacement surgery, a common treatment of severe OA in developed countries, is largely not accessible for the bulk of people in developing countries. This may result in a growing number of older people living with severe joint disease [25] resulting in significant levels of disability for these individuals and increased burden on family members.
Increasing physical activity is an important aspect of managing obesity [96] and lower-limb OA [97]. Further, everyday physical activities in leisure time (excluding high-intensity exercise and gardening or yard work) are strongly associated with a reduced risk of LBP [68]. It is therefore logical for public health initiatives to promote increased physical activity and exercise, along with healthy diet choices, as preventive health strategies for minimising MSK disability and other lifestyle-related diseases. A particular challenge in developing countries may be to find the balance between engaging in physical activities of the type and intensity that are safe and health inducing and fitting in these activities with their work demands and cultural habits. Public health strategies may need to target individuals to empower them to make healthy choices where they have a choice, to encourage employers and schools to promote safe physical activity inworkplace and educational settings [98] and to regulate marketing of products linked to poor health in industry sectors such as the food and drink industry [99].
Conclusions
Globally, MSKs currently cause an enormous amount of disability. With ageing populations and increasing obesity, the total number of people suffering from MSK conditions will increase substantially over the coming decades, requiring greater responsiveness from governments, donors and health service and research providers than currently exists. The current and increasing burden from MSKs is particularly marked in developing countries. The pace of the demographic and epidemiological change in developing countries is such that a forward-looking assessment of future disease burden is critical, while research to assess the most effective and affordable strategies for preventing and managing the burden from MSKs is urgently needed. We are at a unique point in time where it is still possible for countries to address the current burden and prepare for the future burden of MSKs, but action is needed immediately.
Many of the global health initiatives need to expand beyond the traditional ‘top four’ NCD groups by incorporating MSK diseases, in addition to mental and behavioural disorders, in their policies and programmes. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. For these reasons, opportunities for collaboration in the prevention and management of MSK conditions must be explored and encouraged. A better inclusion of MSK conditions will avoid duplication of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Other key opportunities for action include the following: ensuring the principles of ‘development effectiveness’ are met; strengthening leadership and commitment; building the research, information and evidence base, including the collection, analysis and use of quality data; reducing the incidence of MSK conditions through better prevention; and reducing disability from MSK conditions through better management. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs in developing countries.
Practice points
Musculoskeletal (MSK) conditions cause an enormous global burden. This is dramatically increasing in developing countries.
Governments and other donors to aid programmes have traditionally placed the bulk of their funds towards programmes addressing high-mortality communicable diseases. It is critical that there is a major shift in the direction of their funding.
Of those global initiatives that do focus on non-communicable disease (NCDs), there is a need to expand beyond the traditional top four’ NCD groups by incorporating MSK diseases, in addition to mental and behavioural disorders.
Many opportunities exist for a better inclusion of MSKs, which are likely to have significant benefits for reducing the burden of all NCDs.
Research agenda
Research is needed in the following areas related to MSKs in developing countries:
The most effective and affordable strategies for preventing and managing the burden from MSKs.
Ways that MSK initiatives can collaborate and integrate with other NCD initiatives, and initiatives aimed at the general strengthening of health systems in developing countries.
Effective ways for better inclusion of MSK in policies and programmes.
The occurrence, natural history, impact and risk factors of MSKs.
Research needs to be locally focussed, driven by local communities, and have a focus on building local research capacity.
Summary
Globally, MSKs currently cause an enormous amount of disability, and this is particularly marked in developing countries. The pace of the demographic and epidemiological change in developing countries is such that a forward-looking assessment of future disease burden is critical. We are at a unique point in time where it is still possible for countries to address the current burden and prepare for the future burden of MSKs, but action is needed immediately. Many of the global health initiatives need to expand beyond the traditional ‘top four’ NCD groups by incorporating MSK diseases, in addition to mental and behavioural disorders, in their policies and programmes. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. A better inclusion of MSK conditions will avoid duplication of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Research is needed on the most effective and affordable strategies for preventing and managing the burden from MSKs; ways that MSK initiatives can collaborate and integrate with other NCD initiatives, and initiatives aimed at the general strengthening of health systems in developing countries; effective ways for better inclusion of MSK in policies and programmes; and the occurrence, natural history, impact and risk factors of MSKs. Research needs to be locally focussed, driven by local communities, and have a focus on building local research capacity.
Conflict of interests
None declared.
Funding
No funding was received for this work.
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