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Musculoskeletal conditions (2016)

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Topic title Musculoskeletal conditions (2016)
Topic owner Rachel Sokal, Consultant in Public Health
Topic author(s) Laura Dunkley, Public Health Intern
Topic quality reviewed MSK JSNA Task & Finish Group
Current version V1. 19/02/2016
Replaces version New chapter
Linked JSNA topics
Insight Document ID 164064

Executive summary

Introduction

Musculoskeletal (MSK) conditions are those affecting the nerves, tendons, muscles and supporting structures, for example spinal discs[i]. This encompasses over 150 diseases and syndromes[ii]. Taken together, data from the Global Burden of Disease study (GBD) demonstrates that as of 2013 they are the leading cause of disability in England, accounting for 24% of all years lived with disability (YLD)[iii].

According to GBD data, low back and neck pain was the leading cause of disability in England in 2013, resulting in 1.3 million YLD – nearly 18% of all YLD - compared to 445,000 YLD attributable to the next leading cause (sense organ diseases). ‘Other musculoskeletal disorders’ were the tenth largest contributor of YLD, responsible for 235,000 YLD, while osteoarthritis was 15th, causing 136,000 YLD. In Nottingham City, 72% of the musculoskeletal burden (in terms of YLD) is due to low back and neck pain, and 9% due to osteoarthritis. The disability due to MSK disorders is expected to rise further with increases in obesity and sedentary lifestyles, along with an ageing population[iv].

This JSNA chapter focuses on these leading and most common causes of musculoskeletal morbidity and mortality: low back and neck pain and osteoarthritis. It excludes osteoporosis and fracture as this is covered in the separate JSNA chapter ‘Falls and Bone Health’[v]. Rheumatoid arthritis and MSK pain or damage as a result of trauma are also excluded, since in Nottingham these follow slightly different patient pathways and these conditions are less prevalent than neck and back pain, and osteoarthritis.

The impact of MSK conditions can be underestimated since most are not immediately life threatening (although both rheumatoid arthritis[vi],[vii] and, to a lesser extent, osteoarthritis[viii] are associated with increased mortality). Instead, sufferers can live with them for years, resulting in a long-term burden via pain and impaired functioning for the individual which can also impact on social functioning and mental health[ix]. There is also a substantial economic burden due to work days lost and primary and secondary health costs[x]. Official statistics often do not capture the full impact of the illness, as only a small proportion of those with MSK conditions will present to health services and so appear in health data. For example, only around 20% of those with low back pain will present with it to their GP[xi]. As a result, there is a large population of sufferers self-managing their condition at home, for whom the full impact of illness is difficult to capture.

[i] Institution of Occupational Safety and Health (2016) Musculoskeletal disorders. [online] Available at: http://www.iosh.co.uk/books-and-resources/our-oh-toolkit/musculoskeletal-disorders.aspx. [Accessed 19 January 16].

[ii] European Commission (2015) Musculoskeletal conditions. [online] Available at: http://ec.europa.eu/health/major_chronic_diseases/diseases/musculoskeletal/index_en.htm#fragment0. [Accessed 19 January 16].

[iii] Institute for Health Metrics and Evaluation (2015) GBD Compare – Public Health England. [online] Available at: http://vizhub.healthdata.org/gbd-compare/england. [Accessed 14 January 16].

[iv] Storheim, K. and Zwart, J.-A. (2014) Musculoskeletal disorders and the Global Burden of Disease study. Annals of the Rheumatic Diseases;73:949–950.

[v] Nottingham City Council (2015) Falls and Bone Health: Joint Strategic Needs Assessment (JSNA). [online] Available at: http://jsna.nottinghamcity.gov.uk/insight/Strategic-Framework/Nottingham-JSNA/Adults/Falls-and-Bone-Health-(2015).aspx. [Accessed 01 February 16].

[vi] Gonzalez, A., Kremers, H. M., Crowson, C. S., Nicola, P. J., Davis III, J. M., Therneau, T. M., Roger, V. L. and Gabriel, S. E. The widening mortality gap between rheumatoid arthritis patients and the general population. Arthritis & Rheumatism;56(11):3583–3587

[vii] Sihvonen, S., Korpela, M., Laippala, P., Mustonen, J., Pasternack, A. (2004) Death rates and causes of death in patients with rheumatoid arthritis: a population-based study. Scandinavian Journal of Rheumatology;33(4):221-7. Erratum in Scand J Rheumatol. (2006) Jul-Aug;35(4):332.

[viii] Nüesch, E., Dieppe, P., Reichenbach, S., Williams, S., Iff, S and Jüni, P. (2011) All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study. British Medical Journal;342:d1165.

[ix] Woolf, A. D. and Pfleger, B. (2003) Burden of major musculoskeletal conditions. Bulletin of the World Health Organisation;81(9):646-56.

[x] Parsons, S., Ingram, M., Clarke-Cornwell, A. M. and Symmons, D. P. M (2011) A heavy burden: The occurrence and impact of musculoskeletal conditions in the United Kingdom today. Arthritis Research UK and the University of Manchester: Manchester.

[xi] NICE (2009) Low back pain in adults: early management. Clinical guideline CG88. 27 May. NICE: London.

Unmet needs and gaps

Musculoskeletal conditions are often chronic and are the leading cause of disability in England, although a large proportion of sufferers may not present at health services. The impact of these conditions is seen in economic data, including days off work and benefits claimed, as well as in health statistics. There is also a knock-on detrimental impact on mental health. In Nottingham City, 72% of the musculoskeletal burden (in terms of YLD) is due to low back and neck pain, and 9% due to osteoarthritis.

  • Currently there are no data to suggest that levels of low back pain and osteoarthritis in Nottingham differ significantly from national figures and therefore are expected to have the greatest impact on years of life lived with a disability compared to other conditions. Nationwide, the prevalence of MSK conditions is expected to increase due to the ageing population and growing levels of obesity and inactivity. Nottingham may see a disproportionately high rise, due to high levels of child obesity and a greater proportion of deprived areas, which are predicted to have the greatest growth in obesity levels. The impact of MSK conditions on people’s ability to work and function may be greater for those living in deprivation, who are more likely to be in manual occupations.
  • Most MSK sufferers will present at GP as their primary point of call. Nottingham’s MSK pathway directs GPs to manage patients using community services such as physiotherapy for six weeks before they are referred to more specialist services (for example, Integrated Clinical Assessment and Treatment Services). NICE guidelines advocate the promotion of self-management strategies in primary care, and to this end emphasise the importance of providing accurate up-to-date information to the patient to enable effective self-management. It is unclear whether patients across the city currently have equitable access to community services.
  • Some commissioned services are beginning to report on patient outcome data such as improvements in EQ-5D scores, but currently only minimal data is available. Reporting requirements do not always specify an acceptable response rate for outcome surveys, nor exactly how thresholds are defined. It is therefore difficult to ascertain whether services are currently achieving desired clinical outcomes.
  • Evidence suggests that primary assessment by a physiotherapist for MSK conditions can be successful in terms of identifying serious pathology[i], providing satisfactory treatment and reducing demand for a GP[ii]. First line physiotherapy has been rolled out across 20 pilot sites between December 2014 and May 2015.
  • Nottingham City CCG currently commissions an acupuncture service for a range of acute or chronic pain conditions. This is not consistent with NICE guidelines, which recommend this option only for chronic lower back pain, chronic tension-type headaches and migraine. The use of trigger point and facet joint injections, commissioned as part of the Community Pain Service, also has limited evidence of effectiveness.
  • Nottingham City CCG has commissioned and implemented Integrated Clinical Assessment and Treatment Services, including triage, interdisciplinary clinics and case conference. This has seemingly been successful in reducing referrals to secondary care (and associated costs) and facilitating timely access for patients to specialist teams.
  • Data indicate that Nottingham City CCG has a significantly lower rate of hip replacements than average, and that spend on elective care is lower, although there are no data to suggest that the level of need is lower.

 

[i] Harper, L. (2011) Evaluation of drop-in service for patients with low back pain. East Lancashire Hospitals NHS Trust. NICE Shared learning database. [online] Available at: https://www.nice.org.uk/sharedlearning/physiotherapy-low-back-pain-drop-in-services [Accessed 19 February 2016]

[ii] Ludvigsson, M. L., Enthoven, P. (2012) Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Physiotherapy;98(2):131-7.

Recommendations for consideration by commissioners

Prevention and effective management of MSK conditions becomes a strategic priority for Nottingham City. A focus on prevention activities for key risk factors (obesity, physical inactivity) could be expected to mitigate some of the predicted increase in MSK conditions. Recognition should be made that lower socioeconomic groups may be particularly at risk of rising prevalence rates and of facing more limitations due to their condition. 

  • Efforts should be made to increase awareness of preventative and self-management strategies in those suffering from or at risk of MSK disease.
  • As the main bulk of activity will be seen in General Practice, it should be ensured that primary care professionals are aware of local service offerings to enable patients to access them when appropriate.  Primary care professionals should also be well versed on up-to-date information and advice for self-management strategies.
  • It may be that there are inconsistencies in referral practices across the city, so sources of referral to primary care community and specialist MSK services should be evaluated to ensure that patients have equal access to services relative to their needs.
  • Consideration should also be given to how to best support people with ongoing MSK conditions to remain in work.
  • Wherever possible, ongoing evaluation of community services should be embedded, using patient outcome data to appraise services and inform best referral practices. Commissioners and services should ensure to maintain an adequate response rate when collecting patient outcome data, and to measure whether significant clinical benefit has been achieved for patients in terms of pain levels or functioning.
  • Local First-Line Physiotherapy services should be evaluated to ascertain whether they have improved outcomes and been successful in reducing demand in primary care (or whether they have resulted in an increased demand due to increased availability of services). If they are found to be successful, they should be embedded within the MSK pathway and rolled out across the city.  Evaluation should be undertaken to ensure equitable access in relation to clinical need.
  • The service specification for Community Acupuncture should be reviewed and re-commissioned in line with NICE guidance. The use of trigger point and facet joint injections within Pain Management services should also be reconsidered.
  • The level of surgical activity (particularly hip replacements) is below that expected of a similar CCG. This should be investigated further, to ensure that surgical options are made accessible to those who would see an adequate clinical benefit. Pre- and post-surgical measures should be routinely collected and monitored to assist in assessing appropriateness of surgery.

 

Key contacts

 

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