Diffusing the time bomb

There are two fac­tors that most rheuma­tol­o­gists blame for the wave of mus­cu­loskele­tal dis­ease we face: the age­ing UK pop­u­la­tion and our obe­si­ty prob­lem. We can’t do much to hold back the hands of time, admit­ted­ly, but los­ing weight is the fastest way to take a load off your joints.

Some 20 per cent more adults are obese today com­pared with Britain in the Six­ties and a sur­vey by the Depart­ment of Health in 2010 dis­cov­ered that just 57 per cent of peo­ple who were over­weight had tried to shed the extra pounds in the past year.

The British way of life has become much more seden­tary since our par­ents’ gen­er­a­tions. Eight in ten adults in the Six­ties used to have a 30-minute walk every day – now the fig­ure is just half that. The aver­age woman’s waist is six inch­es big­ger than her 1950s coun­ter­part and we do around half the amount of high-ener­gy chores around the house com­pared with the Six­ties.

Sur­geons in the UK have report­ed that the aver­age age of patients hav­ing knee oper­a­tions is get­ting younger. The rea­son? Obe­si­ty.

Of course, our under­stand­ing of mus­cu­loskele­tal dis­ease is bet­ter than it was a few years ago; for exam­ple, the pain dis­or­der fibromyal­gia wasn’t offi­cial­ly recog­nised until 1990. But the preva­lence of com­mon mus­cu­loskele­tal dis­eases and the rate of new diag­noses will force British soci­ety to adapt fast.

Few have begun to real­ly ques­tion what a longer work­ing life will be like for, say, a brick­lay­er with sore joints or a bike couri­er with a hip replace­ment.

There are 70,000 knee replace­ments a year in the UK and the num­ber is ris­ing

Over the last 70 years, Britain has tak­en a mas­sive stride for­ward in terms of some mus­cu­loskele­tal prob­lems. Rick­ets, for instance, has now almost dis­ap­peared, as we realised the impor­tance of a cal­ci­um-rich diet and lat­er the role of vit­a­min D in absorb­ing it. Child­hood dis­eases which warp the skele­ton – name­ly polio and tuber­cu­lo­sis – have also been large­ly elim­i­nat­ed through immu­ni­sa­tion.

Despite being some­thing of a polit­i­cal foot­ball, Britain’s school milk pro­gramme has helped improve the cal­ci­um intake, and thus the bone health, of the country’s poor­est chil­dren. Alto­geth­er, NHS pub­lic health cam­paigns have saved many chil­dren from grow­ing up with bone and joint prob­lems.

A 2011 report by the Uni­ver­si­ty of Manchester’s School of Med­i­cine, A Heavy Bur­den, report­ed the num­ber of peo­ple with rheuma­toid arthri­tis is thought to be in decline, as is the sever­i­ty of new diag­noses.

How­ev­er, the same research report­ed that the inci­dence of gout was con­sis­tent­ly high in men and increased with age – bad news for the age­ing pop­u­la­tion.

Osteo­poro­sis, the most com­mon form of mus­cu­loskele­tal dis­ease in the UK, became more com­mon dur­ing the Eight­ies, accord­ing to the report, and refer­rals for elec­tive hand surgery tre­bled dur­ing the next decade. Back pain report­ed­ly dou­bled between 1956 and 1995.

Despite devel­op­ments in bone and joint health, no cure has yet been dis­cov­ered for arthri­tis or osteo­poro­sis, prob­a­bly because these dis­eases are asso­ci­at­ed with age­ing, although drugs can reduce the symp­toms.

For those suf­fer­ing from painful mus­cu­loskele­tal con­di­tions, pain relief has improved over the last 70 years; aspirin, parac­eta­mol and ibupro­fen have become afford­able for most as drug patents have expired, and the NHS began to pre­scribe the painkillers freely.

The devel­op­ment of bis­pho­s­pho­nates in the 1960s cre­at­ed a new option for patients with osteo­poro­sis and, since the late-Nineties, drugs called tumour necro­sis fac­tor (TNF) inhibitors have helped slow auto-immune dis­eases, includ­ing rheuma­toid arthri­tis and anky­los­ing spondyli­tis.

Judith Brodie, chief exec­u­tive of Arthri­tis Care, says that there is hope, but points out that there is still a key chal­lenge in our way. “There is, over gen­er­a­tions, increas­ing knowl­edge and aware­ness of how best to treat dif­fer­ent forms of arthri­tis and what makes a dif­fer­ence. For instance, pre­scrib­ing TNF inhibitors for rheuma­toid arthri­tis can be trans­for­ma­tive. But, while there have been new treat­ments for pain, that is still a real chal­lenge,” she says.

Man­ag­ing the chron­ic pain that comes with bone and joint dis­ease is still a com­pli­cat­ed busi­ness. The inven­tion of tran­scu­ta­neous elec­tron­ic nerve stim­u­la­tion (TENS) machines in the mid-1970s was a break­through for some patients.

But Arthri­tis Care’s 2012 report OA Nation found that access to treat­ment was lim­it­ed for many patients. A third of peo­ple with osteoarthri­tis nev­er see their doc­tor. For those who do, diag­no­sis is report­ed to be slow; more than a third said it took between three and eleven appoint­ments for a doc­tor to diag­nose the con­di­tion.

The cost of car­ing for Britain’s bones will boom over the next 20 years. Cost of treat­ing and car­ing for hip frac­tures in the UK could top £6 bil­lion by 2036, accord­ing to Age UK. Falls and frac­tures will increase emer­gency admis­sions, one of the biggest areas of NHS spend­ing already. But bone and joint con­di­tions are also due to take a big­ger chunk of pre­scrib­ing bud­gets.

Patients incor­rect­ly mix­ing NSAIDs (non-steroidal anti-inflam­ma­to­ry drugs), such as aspirin and ibupro­fen, with oth­er drugs is also respon­si­ble for many emer­gency admis­sions to hos­pi­tal, the major­i­ty of which are for elder­ly peo­ple with, in some cas­es, numer­ous oth­er ill­ness­es.

Pain, lack of mobil­i­ty and flex­i­bil­i­ty also affect the British econ­o­my when employ­ees’ poor bone and joint health forces them to take time off or even quit work. The Health and Safe­ty Executive’s 2010 report on age­ing and mus­cu­loskele­tal dis­or­ders found that, despite work­places valu­ing their more senior employ­ees, lit­tle is being done to keep these peo­ple at work. It con­cludes: “An old­er work­force has impli­ca­tions [which] include pro­vid­ing addi­tion­al sup­port for work­er require­ments, chang­ing the work­place atti­tudes towards age­ing, pro­vid­ing a pos­i­tive knowl­edge base, adjust­ing the work­place design and accom­mo­da­tions, and improv­ing work­er-employ­er rela­tion­ships [co-oper­a­tion].”

The impli­ca­tion was that, even two years ago, most UK employ­ers were not even at the first stage of this enor­mous, but nec­es­sary, change.

Sur­geons report that patients for knee oper­a­tions are get­ting younger and some have called for bet­ter test­ing of implants. Fifty-some­things receiv­ing new knees and hips have a much more active lifestyle than the aver­age implant can­di­date ten years ago, and are like­ly to be using them for longer as the aver­age lifes­pan extends. There are 70,000 knee replace­ments a year in the UK and the num­ber is ris­ing.

The grow­ing num­ber of peo­ple with mus­cu­loskele­tal dis­ease will also have a some­what more sober­ing psy­cho­log­i­cal impact on patients. Med­i­cine is already fail­ing to deal with the impact of chron­ic pain on patients like Nan Mait­land, who cit­ed arthrit­ic pain as the rea­son for her assist­ed sui­cide in Switzer­land in 2011.

While the dis­ease is not a ter­mi­nal diag­no­sis, Arthri­tis Research UK says that sev­en in ten patients feel depressed when the pain of the dis­ease is at its worst. Mus­cu­loskele­tal dis­ease is typ­i­cal­ly char­ac­terised by pain and, as patients find them­selves less able to work, socialise and pur­sue their inter­ests, con­di­tions start to impact on men­tal health and well­be­ing.

As the NHS adapts to its new clin­i­cal­ly-led struc­ture, clin­i­cal com­mis­sion­ing groups (CCGs) – the groups of GPs who will be in charge of NHS bud­gets – will have the chance to make new invest­ments in mus­cu­loskele­tal dis­ease care.

How­ev­er, the so-called “Nichol­son chal­lenge” of mak­ing effi­cien­cy sav­ings of £15 bil­lion to £20 bil­lion between 2011 and 2014, will force these GP-led groups to make sig­nif­i­cant cut­backs.

Hos­pi­tal admis­sions and refer­rals have already been heav­i­ly restrict­ed; knee surgery or replace­ment and hip oper­a­tions have been rationed by some pri­ma­ry care trusts and CCGs. Pre­scrib­ing bud­gets have been slashed, and many GPs have cho­sen to focus on oth­er com­mon long-term con­di­tions, such as dia­betes and chron­ic obstruc­tive pul­monary dis­ease, rather than mus­cu­loskele­tal prob­lems.

Self-care and self-man­age­ment are buzz words cit­ed by health econ­o­mists as a quick route to cost sav­ings; it is like­ly that some patients suf­fer­ing from pain will be encour­aged to try to man­age their symp­toms them­selves using painkillers, exer­cise pro­grammes and self-mas­sage. While this pre­scrip­tion will no doubt alle­vi­ate some symp­toms, a num­ber of patients will ulti­mate­ly feel they have been left to deal with their con­di­tions them­selves.

Whether self-care is an appro­pri­ate sug­ges­tion for patients suf­fer­ing from mus­cu­loskele­tal prob­lems is a dif­fi­cult ques­tion. What is not debat­able is that these dis­eases will force huge changes to the way we work and the way we man­age NHS resources for the fore­see­able future.

There are two factors that most rheumatologists blame for the wave of musculoskeletal disease we face: the ageing UK population and our obesity problem. We can’t do much to hold back the hands of time, admittedly, but losing weight is the fastest way to take a load off your joints.