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Musculoskeletal Disorders as a Public Health Concern

Policy Date: 11/1/2011
Policy Number: 20114

Musculoskeletal disorders are a major source of morbidity in the United States. Healthy People 2010 and Healthy People 2020 both list physical activity as one of the leading health indicators,[1,2] and musculoskeletal disorders are among the most common causes of disability and subsequent lack of physical activity.[3,4] Musculoskeletal disorders represent a burden on society in both direct costs to the health care system and indirect costs through loss of work and productivity.[5] Evidence-based treatment and prevention measures are available, but there is a need to increase the awareness of these interventions among health care providers and the population at large.[6–16] There is also a need to encourage future research to elucidate more interventions for the treatment and prevention of these disorders and to promote the health of people with a musculoskeletal disability. For example, musculoskeletal conditions such as chronic lower back pain and osteoarthritis are listed among the research priorities of the Institute of Medicine.[17] The Agency for Healthcare Research and Quality is a resource for guidelines on topics such as lower back pain, osteoporosis, fall prevention in the elderly, and many other topics.[18] There are currently 216 guidelines pertaining to musculoskeletal diseases. Other helpful guidelines include those of the US Preventive Services Task Force (www.uspreventiveservicestaskforce.org) and the Guide to Community Preventive Services (www.thecommunityguide.org). These guidelines provide an excellent resource to guide health care workers on evidence-based strategies. These resources are often not used by health care workers, and they need to be more accessible. There is also a need to clarify the guidelines when contradictory information is presented.

Problem Statement
Musculoskeletal disorders and diseases are the leading cause of disability in the United States, accounting for more than one half of all chronic conditions in people aged older than 50 years in developed countries.[19] The economic impact of these conditions is also staggering: in 2004, direct expenditures in health care costs and indirect expenditures in lost wages were estimated to total $849 billion, or 7.7% of the national gross domestic product.[20] The goal of this policy statement is to encourage the development and dissemination of educational initiatives and materials to address musculoskeletal disorders as a public health problem, to increase advocacy for important public health legislation, and to inform and train public health and health care workers in the prevention, treatment, and ongoing health promotion for people with musculoskeletal disabilities through public and professional educational programs.

Scientific Issues
Worldwide, musculoskeletal conditions are the most common causes of severe long-term pain and physical disability.[21,22] The World Health Organization (WHO) estimated that about 30% of back pain worldwide was due to working conditions.[23] In some segments of the workforce, ergonomic hazards account for more than 50% of all musculoskeletal disorders.[24] Health care workers are especially affected by heavy lifting, such as patient and resident handling. The rate of back injuries in the health care and social services sector is nearly 1.5 times greater than for private industry as a whole, and this risk accounts for a large proportion of nurses and other direct care workers leaving the job.[39,40]

Aging populations throughout the developed world will result in increased numbers of people suffering from musculoskeletal conditions, resulting in increased costs to those countries.[27] Joint diseases account for half of all chronic conditions in the elderly.[27] Forty percent of all women aged older than 50 years are expected to suffer at least one osteoporotic fracture in their lifetime,[18] and osteoporotic fracture is associated with increased mortality.[28,29] Throughout the world, musculoskeletal conditions and deformities deprive children of a normal development.[30–32] Road traffic injuries are increasing precipitously and, by the year 2010, are estimated to account for as much as 25% of all health care expenditures in developing nations.[33–35]

In the United States alone, musculoskeletal conditions are a leading cause of disability, accounting for more than 130 million patient visits to health care providers annually. They are the number-one reason people visit their physician, and they affect nearly half of Americans older than 18 years.[20]

There are evidence-based interventions that can be used to educate the public on the prevention of these disorders. Examples are as follows:
1. Osteoporosis prevention programs.[6,11]

2. Fall prevention programs.[7]

3. Public education programs resulting in reduced resource utilization.[8]

4. Programs addressing back pain or increased physical activity.[12–16]
5. Safe lifting programs for health care workers.[36,37]
6. Workplace ergonomics programs for both primary and secondary prevention.[24]

Many of these programs, despite having strong scientific support, have been implemented only on a limited basis, for a variety of reasons.[38]
A common issue involving preventive strategies is that there is a need to develop “system-wide” strategies to educate society about the importance of health promotion, prevention, and treatment of musculoskeletal disorders. Public education campaigns have been developed that could easily be implemented by public health workers. This implementation of simple educational programs has the potential to reduce the future burden of musculoskeletal diseases on society through prevention. Some of these programs include public education programs developed by organizations such as the US Bone and Joint Decade/Initiative. These programs include a focus on topics such as arthritis education (Experts in Arthritis), osteoporosis prevention and awareness (Fit to a T), education of high school students about the importance of protecting their bones and joints (PB&J), a public education campaign on the importance of improving posture (Straighten Up America), and also educational and research initiatives aimed at improving the quality of education in medical schools concerning musculoskeletal disorders (usbjd.org). Safe patient handling programs have been shown to reduce back injury rates substantially in hospitals and nursing homes.[25,37] Patient lift assist equipment also prevents patient injury from skin tears or unanticipated falls during lifting.[25]
Additional programs also are available through other organizations; in Australia, for example, there is a program for fall prevention (www.fallssa.com.au). Other educational materials are available through organizations such as the Arthritis Foundation (www.arthritis.org), the American College of Rheumatology (www.rheumatology.org), and the American Nurses Association (www.nursingworld.org).[39] It is of note that many of these public education campaigns have taken place in areas outside of the United States. They have demonstrated improvements in attitudes about these disorders and have shown slight improvements in behavior. There is a need to further develop and evaluate these types of programs in the United States in order to determine if there are unique differences between countries.[12–16] In addition to these resources, APHA calls for further research to develop evidence-based strategies for prevention and treatment of these disorders. It is also necessary to develop educational materials concerning musculoskeletal disorders for special populations, such as ethnic minorities, non-English speakers, and people with disabilities,[38,40–42] because (1) there are unique attitudes toward pain and disability among ethnic minorities[40] and (2) there is a significant lack of educational materials for people with developmental disabilities concerning pain for either the disabled adult or their caregivers.[43]

In conclusion, a considerable public health burden is associated with musculoskeletal diseases, which, in many cases, can be prevented or treated through evidence-based programs. There is currently a lack of implementation of these evidence-based educational programs addressing the prevention and treatment of musculoskeletal disorders. There is a need for organizations serving the public to educate the public and health care professionals on the importance of addressing musculoskeletal disorders. APHA also can encourage legislation to increase preventive services through public education campaigns similar to those that have been successfully implemented in other countries.[8–10] APHA also can partner with government agencies, private foundations, and academic or professional societies (e.g., the American College of Rheumatology, the Osteoarthritis Research Society, and the National Osteoporosis Foundation) to encourage an increase in funding for improved treatment of musculoskeletal disorders.

Therefore, APHA—
1. Calls on public health agencies to make available evidence-based musculoskeletal programs and resources to public health and health care workers. These are offered through organizations such as the Arthritis Foundation and Bone and Joint Decade/Initiative. Examples include the following: The Arthritis Help Book (Arthritis Foundation; www.arthritis.org); Burden of Musculoskeletal Disease (www.usbjd.org); National Council on Aging: Fall Prevention Checklist (www.healthyagingprograms.org); Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (http://www.osha.gov/ergonomics/guidelines/nursinghome); Laboratory Safety–Ergonomics for the Prevention of Musculoskeletal Disorders in Laboratories (http://www.osha.gov/Publications/laboratory/OSHA3404laboratory-safety-guidance.pdf); Computer Workstations e-Tool (http://www.osha.gov/SLTC/etools/computerworkstations) and others (www.osha.gov); Elements of Ergonomics Programs (http://www.cdc.gov/niosh); Preventing Work-Related Musculoskeletal Disorders in Sonography (http://www.cdc.gov/niosh/docs/wp-solutions); Simple Solutions: Ergonomics for Construction Workers (http://www.cdc.gov/niosh/docs); and others (www.cdc.gov/niosh).

2. Encourages the development of culturally and linguistically appropriate educational materials and methods for special populations, such as ethnic minorities, non-English speakers, and people with developmental disabilities, focusing on prevention, treatment, and rehabilitation of specific musculoskeletal disorders.

3. Urges the further development and dissemination of evidence-based guidelines for the prevention and management of musculoskeletal disorders.

4. Encourages further investigation into the effectiveness of public education campaigns focusing on attitude and behavioral change concerning musculoskeletal disease in the United States.

5. Recommends advocacy for public health legislation that supports the prevention and management of musculoskeletal disorders, such as the physical activity recommendations as outlined in Healthy People 2010.

1. Healthy People 2010. 2 vol. Washington, DC: US Dept of Health and Human Services; 2000.
2. US Dept of Health and Human Services. Healthy People 2020 objective topic areas. Updated February 7, 2011. Available at: http://healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objectives.pdf. Accessed February 18, 2011.
3. Chan G, Chen CT. Musculoskeletal effects of obesity. Curr Opin Pediatr. 2009;21(1):65–70.
4. Merikangas KR, Ames M, Cui L, et al. The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Arch Gen Psychiatry. 2007;64(10):1180–1188.
5. Côté P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(4 suppl):S60–S74.
6. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(10 suppl):S1–34.
7. Sleet DA, Moffett DB, Stevens J. CDC’s research portfolio in older adult fall prevention: a review of progress, 1985–2005, and future research directions. J Safety Res. 2008;39(3):259–267.
8. Buchbinder R. Self-management education en masse: effectiveness of the Back Pain: Don’t Take It Lying Down mass media campaign [review]. Med J Aust. 2008;189(10 suppl):S29–S32.
9. Dreinhöfer KE, Reichel H, Käfer W. Strategies for prevention and management of musculoskeletal conditions. Lower limb pain. Best Pract Res Clin Rheumatol. 2007;21(1):135–152.
10. Jensen I, Harms-Ringdahl K. Strategies for prevention and management of musculoskeletal conditions. Neck pain. Best Pract Res Clin Rheumatol. 2007;21(1):93–108.
11. Ceausu I. Education and information: important tools in assessing the risks and prevention of osteoporosis fractures. Climacteric. 2010;13(6):530–533.

12. Gross DP, Russell AS, Ferrari R, et al. Evaluation of a Canadian back pain mass media campaign. Spine. 2010;35(8):906–913.

13. Buchbinder R, Jolley D. Effects of a media campaign on back beliefs is sustained 3 years after its cessation. Spine. 2005;30(11):1323–1330.
14. Buchbinder R, Jolley D. Improvements in general practitioner beliefs and stated management of back pain persist 4.5 years after the cessation of a public health media campaign. Spine. 2007;32(5):E156–E162.
15. Waddell G, O’Connor M, Boorman S, Torsney B. Working Backs Scotland: a public and professional health education campaign for back pain. Spine. 2007;32(19):2139–2143.
16. Warburton DE, Katzmarzyk PT, Rhodes RE, Shephard RJ. Evidence-informed physical activity guidelines for Canadian adults. Can J Public Health. 2007;98(suppl 2):S16–S68.
17. Institute of Medicine. Initial National Priorities for Comparative Effectiveness Research. Washington, DC: National Academies Press; 2009.
18. Weinstein S. The Bone and Joint Decade. J Bone Joint Surg Am. 2000;82:1–3.
19. National Guideline Clearing House. Available at: http://www.guideline.gov/index.aspx. Accessed December 19, 2001.
20. Watkins-Castillo S, ed. The Burden of Musculoskeletal Disease in the United States. Rosemont, IL: American Academy of Orthopedic Surgeons; 2008.
21. Piedrahita H. Costs of work-related musculoskeletal disorders (MSDs) in developing countries: Colombia case. Int J Occup Saf Ergon. 2006;12(4):379–386.
22. Louw QA, Morris LD, Grimmer-Somers K. The prevalence of low back pain in Africa: a systematic review. BMC Musculoskelet Disord. 2007;8:105.
23. Punnett L, Prüss-Üstün A, Nelson DI, et al. Estimating the global burden of low back pain attributable to combined occupational exposures. Am J Ind Med. 2005;48(6):459–469.
24. National Research Council, Institute of Medicine. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: National Academy Press; 2001.
25. State of the Sector. Healthcare and Social Assistance: Identification of Research Opportunities for the Next Decade of NORA. Atlanta, GA: National Institute for Occupational Safety and Health; August 2009. DHHS (NIOSH) publication 2009–139.
26. Estryn-Behar M, Le Nézet O, Jasseron C. Health and satisfaction of healthcare workers in France and in Europe. Report to the European Commission from SALTSA (Joint Programme for Working Life Research in Europe), 2005. Available at: http://www.presst-next.fr/pdf/brochureengl3.pdf. Accessed December 19, 2011
27. Leveille SG. Musculoskeletal aging. Curr Opin Rheumatol. 2004;16(2):114–118.
28. Lau E, Ong K, Kurtz S, Schmier J, Edidin A. Mortality following the diagnosis of a vertebral compression fracture in the Medicare population. J Bone Joint Surg Am. 2008;90(7):1479–1486.
29. Kim DH, Vaccaro AR. Osteoporotic compression fractures of the spine; current options and considerations for treatment [review]. Spine J. 2006;6(5):479–487.
30. Nassonov EL. Musculoskeletal disorders in Russia at the end of the 20th century. J Rheumatol Suppl. 2003;67:56–58.
31. Driscoll SW, Skinner J. Musculoskeletal complications of neuromuscular disease in children. Phys Med Rehabil Clin N Am. 2008;19(1):163–194, viii.
32. Adegbehingbe OO, Fatusi AO, Adegbenro CA, Adeitan OO, Abass GO, Akintunde AO. Musculoskeletal disorders: epidemiology and treatment seeking behavior of secondary school students in a nigerian community. Indian J Community Med. 2009;34(2):140–144.
33. Bener A, Rahman YS, Mitra B. Incidence and severity of head and neck injuries in victims of road traffic crashes: in an economically developed country. Int Emerg Nurs. 2009;17(1):52–59.
34. Riewpaiboon A, Piyauthakit P, Chaikledkaew U. Economic burden of road traffic injuries: a micro-costing approach. Southeast Asian J Trop Med Public Health. 2008;39(6):1139–1149.
35. Stevenson M, Yu J, Hendrie D, et al. Reducing the burden of road traffic injury: translating high-income country interventions to middle-income and low-income countries. Inj Prev. 2008;14(5):284–289.
36. Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders. Washington, DC: Occupational Safety and Health Administration, US Dept of Labor; 2009. OSHA publication 3182-3R.
37. Nelson A, Baptiste A. Evidence-based practices for safe patient handling and movement. Online Journal of Issues in Nursing. 2004;9(3). Available at: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/EvidenceBasedPractices.aspx. Accessed December 19, 2011.
38. Loisel P, Buchbinder R, Hazard R, et al. Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence. J Occup Rehabil. 2005;15(4):507–524.
39. American Nurses Association. Position statement on elimination of manual patient handling to prevent work-related musculoskeletal disorders. 2003. Available at: http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/SafePatient/Resources/HandlewithCare.pdf. Accessed December 19, 2011.
40. Shavers VL, Bakos A, Sheppard VB. Race, ethnicity, and pain among the US adult population. J Health Care Poor Underserved. 2010;21(1):177–220.
41. Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10(12):1187–1204.
42. New pain management standards: 4 questions surveyors are asking. ED Manag. 2000;12(7):73–80.
43. Blomquist KB, Brown G, Peersen A, Presler EP. Transitioning to independence: challenges for young people with disabilities and their caregivers. Orthop Nurs. 1998;17(3):27–35.