Musculoskeletal Disorders as a Public Health Concern

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. 

References

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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. 
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