EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

5. HEALTH IMPACTS OF NON COMMUNICABLE DISEASES AND RELATED TIME-TRENDS

5.6. Musculoskeletal conditions and problems

5.6.3. Data description and analysis

Links:  Standard Highlighted

Link to concordances are always highlighted on mouse hover

5.6.3. Data description and analysis

 

The major musculoskeletal problems and conditions and their impact are described in the following section in terms of definitions, incidence and prevalence; determinants; disability and quality of life; health care utilization; economic impact and future trends. Estimates of incidence and prevalence for the major musculoskeletal conditions and problems for a Caucasian European population derived from studies in Europe and North America (Symmons, 2003) are given in table 5.6.1.

 

Table 5.6.1. General Incidence and Prevalence Rates

 

Musculoskeletal Pain and Disability

 

Definitions

 

Musculoskeletal pain is experienced by most people at some time.

 

Musculoskeletal pain may be associated to a specific musculoskeletal condition or be a regional or generalized pain problem. It can be acute and transient, such as following injury; recurrent as is often the situation with low back pain; or may be chronic as is usually the situation with osteoarthritis and rheumatoid arthritis.

 

Prevalence

 

In Europe, just over one-fifth (22%) of the population currently has, or has experienced long-term muscle, bone and joint problems such as rheumatism and arthritis (Eurobarometer Special Report No 272e, 2007). A survey in Norway found that only 15% of 20-72 year-olds reported no pain during the previous year, whereas 58% reported musculoskeletal pain during the previous week and 15% had musculoskeletal pain every day during the previous year ( Natvig et al, 1995). They were the most common self-reported chronic sickness in men and women from 16 to 74 years of age in the UK General Household Survey 2002 (Office for National Statistics UK, 2002) and almost as common as cardiovascular conditions in those over 75.

 

The prevalence of musculoskeletal pain increases mainly up to about 65 years of age (Andersson et al, 1993; Bergman et al, 2001; Hagen et al, 1997) (Figure 5.6.1), explained partly by a cumulative effect of chronic musculoskeletal conditions, which become more prevalent with older age (Figure 5.6.2). A decline in the complaint of pain has been noticed over 65 years of age; a plausible explanation for this could be the decline around the age of retirement of the adverse physical and mental effects of the working place.

 

Figure 5.6.1. The age and sex-specific prevalence of musculoskeletal pain (95% Cl) among all respondents (n=2755) in Sweden

 

 

Figure 5.6.2. Prevalence of self reported musculoskeletal diseases per age group in the Netherlands

 

Figure 5.6.2.b Prevalence of self reported musculoskeletal diseases per age group in the Netherlands (different group of diseases)

 

Disability and quality of life

 

Musculoskeletal conditions are associated with the poorest quality of life if compared to other chronic conditions (Sprangers et al, 2000), in particular related to physical functioning, role functioning and pain.

 

Musculoskeletal conditions are the leading cause of disability for both men and women, as well as for the whole population and the elderly (Picavet and van den Bos, 1997). Musculoskeletal pain is usually associated to limitations of activities and restricted participation (European Commission (2004): European Action Towards Better Musculoskeletal Health), which is greater with more widespread pain, back pain and knee pain (Urwin et al, 1998). In the Eurobarometer Survey just under a third (32%) of all respondents said that in the week preceding their interview they experienced muscle, joint, neck or back pain which affected their daily activities and a quarter of all EU respondents say that at some point in their life they have experienced chronic restrictive musculoskeletal pain (Eurobarometer Special Report No 272e, 2007).

 

The prevalence of physical disabilities due to a musculoskeletal condition has repeatedly been estimated to be 4-5% of the adult population (Reynolds et al, 1992). The prevalence is higher in women, and increases strongly with age.

 

In the UK, a report on disabled adults from the Office of Population Census and Surveys, found that 30% of disabled people had arthritis (Office for National Statistics, 1989).

 

A large population study, The Calderdale study (Badley and Tennant, 1993), which utilised a clinical validation of rheumatic diagnosis and disability, found that 24% of the whole population reported some joint problems. Of those adults with a rheumatic disorder, 8.2% were disabled and of these approximately 5% reported arthritis, mainly osteoarthritis, as the cause.

 

Musculoskeletal conditions are a major cause of disability adjusted life years (DALYs) and years lived with disability (YLDs). They are seldom fatal and the level of disability for many is low to moderate. Musculoskeletal conditions rank in the top 10 causes of DALY in Europe (WHO European Strategy for NCD 2006) and osteoarthritis is the 5th greatest cause of YLDs in high-income countries (Lopez et al, 2006).

 

Health care utilization

 

Musculoskeletal problems are a very common reason for primary care consultation even though 20-39% of people with musculoskeletal problems do not consult a primary care physician (Lock et al, 1999; Woolf et al, 2004). Musculoskeletal conditions are major reason for patients to seek expert referral for (Lin et al, 2000), see physiotherapists and complementary therapists and use alternative medications or supplements. Over three quarters of patients presenting to practitioners of the major complementary disciplines have a musculoskeletal problem as their main complaint (Zollman and Vickers, 1999).

 

In the Swedish Cost of Illness Study, musculoskeletal conditions were the most expensive disease categories representing 22.6% of the total cost of illness (Jacobson and Lindgren, 1996).

 

Economic impact

 

Musculoskeletal problems are the most common cause of health problems limiting work in developed countries, with up to 60% of people on early retirement or long-term sick leave claiming them as the reason (Swedish Yearbook of Health and Medical Care, 2001).

 

In the Netherlands, musculoskeletal conditions ranked second as a health care cost in 1994 (Meerding et al, 1998), accounting for 6% of total health care costs compared to 8.1% for mental retardation. Coronary heart diseases and other circulatory diseases accounted for 4.8%. This study only considered medical costs. The inclusion of indirect costs, such as informal care would have greatly increased the costs related musculoskeletal diseases as studies have shown that for osteoporosis and arthritis the healthcare costs only represent between a quarter and a third of the total costs. The costs were considerable at all ages, ranking fifth at 1544, second at 4564 and third at age 6584 after dementia and stroke.

 

Osteoarthritis

 

Definition

 

Osteoarthritis (OA) is characterised by focal areas of loss of articular cartilage within synovial joints, associated with hypertrophy of bone (osteophytes and subchondral bone sclerosis) and thickening of the capsule. OA can affect any joint, but is most common in the hand, spine, knee, foot and hip. This pathological change, when severe, results in radiological changes (loss of joint space, sclerosis and osteophytes) that have been used in epidemiological studies to estimate the prevalence of OA in different joint sites (Kellgren and Lawrence, 1958). Clinically, the condition is characterized by joint pain, tenderness, limitation of movement, crepitus, occasional effusion and variable degrees of local inflammation.

 

Case definition can be based on pathological changes seen on x-rays, by the presence of joint symptoms or require both. It can also be related to the affected joints. The preferred definition for OA includes both x-ray findings and the presence of joint pain most days (Altman et al, 1986).

 

Natural history

 

The course of the disease varies but is often progressive with radiographic changes slowly deteriorating in the hands (Kallman et al, 1990), knees (Dougados et al, 1992), and hips (Danielsson, 1964), leading to increased pain and disability (Dougados et al, 1992). Progression of OA is accelerated by age, and in the hip and knee by obesity and intensive physical activity (Table 5.6.4). The pain and disability associated with OA increases with progressive joint damage.

 

Incidence

 

The incidence of osteoarthritis is problematic to estimate and there are little data because of its gradual progressive development and difficulties in the definition of a new case. It can be estimated by the number presenting to health care with OA by agreed criteria. An estimation of the incidence of severe osteoarthritis may be obtained from the figures of the progression of radiological osteoarthritis from a low to a higher radiological score, with or without the onset of clinical symptoms. Data is not available for all EU countries. However, major differences in the epidemiology of risk factors, such as obesity, may result in inter-country variation.

The incidence and rate of progression increases with age.

 

Prevalence

 

Prevalence measured using radiological criteria alone can lead to overestimates of the burden of disease as radiological changes are not always accompanied by symptoms. The presence of knee pain without an examination or radiograph to confirm causation will also lead to an overestimate of prevalence. Likewise, surveys that ask for self-reported chronic conditions including osteoarthritis over-estimate the prevalence (Symmons et al, 2003). For example, a study of women aged 45-65 in the UK showed that the prevalence of symptomatic knee OA was 2.3% compared to 17% based on radiologically defined knee OA (Spector et al, 1991).

 

The prevalence of OA increases indefinitely with age as OA is not reversible (Figures 5.6.3 and 5.6.4 and Tables 5.6.1-5.6.3) and this is where the burden lies. Surveys show that osteoarthritis changes are uncommon in those under the age of 40 but are seen in most over the age of 70 (van Saase et al, 1989). For example, in people aged 5574 the prevalence of OA of the hand is 70%, foot OA 40%, knee OA 10% and hip OA 3% (Lawrence et al, 1998).

 

Men are affected more often than women among those aged <45, whereas women are affected more frequently among those aged >55 (Petersson and Jacobsson, 2002). There are insufficient data to know if there is any geographical variation in prevalence.

 

In many people there will be several joints involved and it is estimated in the Global Burden of Disease study that approximately 10% of the population 60 years old or older have symptomatic problems that can be attributed to OA (Symmons et al, 2003).

 

Table 5.6.2. Osteoarthritis Incidence in selected European countries

 

Table 5.6.3. Osteoarthritis Prevalence in selected EUGLOREH Countries

 

Table 5.6.4. Osteoarthritis Prevalence (Radiographic Criteria) in selected European Countries  

 

Figure 5.6.3. Prevalence of knee OA in Europe

 

Figure 5.6.4a. Prevalence of radiographic OA by age A) Men

Figure 5.6.4b. Prevalence of radiographic OA by age B) Women

 

Determinants, risk factors and population at risk

 

Age is the strongest predictor of the development and progression of radiographic OA (Table 5.6.4). Almost everyone who reaches 90 years of age will have OA in some joint (Petersson and Jacobsson, 2002).

 

OA is more common in females, increasing at the age of 50 especially in the hand and knee. The role of the menopause is unclear but hormone replacement therapy (HRT) is associated with a reduced risk of the development and progression of knee OA (Petersson and Jacobsson, 2002).

 

Obesity (BMI) is a risk factor for the development of OA of the hand, knee and hip and for progression in the knee and hip (Woolf, 2007). One study showed obesity to result in an odds ratio of about 8.0 for developing OA knee (Davis et al, 1990). It is estimated that a decrease of 2 BMI units would decrease the risk of developing knee OA by 20-30% (Felson, 1996).

 

Trauma, particularly in men, is associated with development of knee OA. Other mechanical factors and intensive activity are risk factors for the development of OA of the knee and hip shown by associations with malalignment, repeated knee bends or squatting, intensive sports activities and certain physically demanding occupations (Petersson and Jacobsson, 2002).

 

Farming presents the greatest relative risk for OA: 4.5 for farming 1-9 years and 9.3 for farming ten years or more when compared to sedentary occupations  (Croft et al, 1992).

 

There is a negative association between osteoarthritis and smoking (Felson et al, 1996).

 

These risk factors are summarised in table 5.6.5.

 

Table 5.6.5. Risk factors for incidence and progression of osteoarthritis of the knees, hips, and hands.

 

Impact

 

Osteoarthritis of the hip, knee and hand are the most important from the point of view of public health, based on their prevalence and associated disability. Osteoarthritis results in pain, loss of motion of affected joints, which limits related activities such as manual dexterity and mobility. Osteoarthritis of the knee is a major cause of mobility impairment, particularly among females.

 

OA was estimated to be the 5th leading cause of non-fatal burden of disease in high income countries in 2001 measured as healthy life lost as a result of disability (Global burden and risk factors 2006) .

 

Economic impact is a consequence of work loss, and of social and health care. There is little data available specifically for OA. However in Sweden, osteoarthritis was estimated to incur SEK 7.4 billion (Euro 690 million)  in 1994, of which SEK739 million (Euro 59.6 million) was for inpatient care and SEK 6.4 billion (Euro 630.4 million)  for productivity losses (Jonsson and Husberg, 2000). In France estimates of the costs of osteoarthritis from national data were 0.1% of 1991 GNP, of which almost two-thirds were direct costs of medical care (Levy et al, 1993). OA is a major cause of chronic pain and disability resulting in analgesic and NSAID usage, and rehabilitation. Joint replacement is a major cost. Total hip replacement rates, usually for OA, vary in OECD countries between 50 and 140 procedures / 100,000 (Merx et al, 2003). The estimated requirement for knee replacement is 27.4 joints per 1000 people aged 35 or more according to severity of knee disease (Juni et al, 2003).

 

Future trends

 

Future changes in the incidence and prevalence of OA are difficult to predict. As incidence and prevalence rise with increasing age and obesity, extending life expectancy will result in greater numbers with OA and greater disability. The burden however may be controlled by joint replacement surgery although the costs of this will be considerable and strategies for prevention are central to controlling the burden.

 

Rheumatoid arthritis

 

Definition

 

Rheumatoid arthritis (RA) is an inflammatory condition that predominantly affects synovial joints. It is the most common form of chronic polyarthritis. The established disease is distinguished from other forms of arthritis by various criteria, with ACR as the preferred criteria (Arnett et al, 1988).

 

However, it is difficult at onset to distinguish inflammatory polyarthritis that will persist and develop the features of rheumatoid arthritis from that which will resolve or progress into another form of chronic arthritis. At present, there is much research trying to solve this issue and identify rheumatoid arthritis at the earliest stage to allow early treatment. Recently, recommendations have been made for early diagnosis inclusive of the anti-cyclic citrullinated peptide antibodies marker (Combe et al, 2007).

 

Natural history

 

Inflammatory polyarthritis has a remission rate of 30-40% in inception cohort studies, whilst there is little evidence of persistent disease in population studies in 75% of people after 5 years. However the remission in those classified as already having RA at presentation is lower, namely around 10-30%. Clinic-based established cases have a far worse prognosis and until the 1980’s most had significant progression over 10 years with few being controlled on symptomatic therapy alone. Spontaneous remission rates are only 5-7% with a median duration of 10 months. There is also an increased mortality associated with RA (EULAR Online Course, 2008).

 

Modern treatment is effective in controlling disease activity and reducing long-term disability. Early treatment aimed at controlling disease activity is the present strategy to prevent this disability (European Commission (2004): European Action Towards Better Musculoskeletal Health).

 

Incidence

 

A review of European studies using the 1987 ACR criteria (European Commission (2003): Indicators for Monitoring Musculoskeletal Problems and Conditions) gives estimates of the annual incidence of RA range from 413 per 100,000 for adult males and 13-36 per 100,000 for adult females. Estimates of the prevalence of RA range from 1-6 per 1000 for men and 3-12 per 1000 for women. In all studies the prevalence is higher in women than men (the ratio varied from 1.7 to 4.0) .

 

The incidence of RA in women appears to have fallen between the 1960s and 1980s and has stabilised since 1980s. This fall is now reflected in recent prevalence figures for RA from the UK which show that, since the 1960s, there has been an approximate 25% fall in prevalence in women aged 16-74.

 

The incidence and prevalence of RA generally rises with increasing age until about the age of 70, to then decline (Linos et al, 1980). (Table 5.6.6)

 

Table 5.6.6. Prevalence and incidence of rheumatoid arthritis from individual studies across Europe.

 

Prevalence

 

For both men and women there appears to be a gradient in the prevalence of RA going from South (lowest) to North (highest). For example the prevalence of RA in men in Finland is reported as 0.6%, France 0.32% and Italy 0.13%. In women, the prevalence in the same three countries is 1%, 0.86% and 0.51%. These figures are not directly comparable because they are not age standardised; nevertheless, the pattern seems clear.

 

Determinants, risk factors and the population at risk

 

RA tends to run in families. One of the genetic components of seropositive RA has been mapped to a short gene sequence now known as the shared epitope. This appears to be the marker for RA disease severity rather than susceptibility (Weyand et al, 1992).

 

Little is known about the environmental triggers for RA. Infection may play a part in some individuals. There are complex interactions between the female sex hormones and RA. The onset of RA is rare during pregnancy and RA is more common in nulliparous women. The oral contraceptive pill, or some other factor associated with its use, apparently protect against the development of the severe RA. Again the frequency of the pill use, nulliparity and breast-feeding varies considerably between communities and may influence the epidemiology of RA. Smoking and obesity are also risk factors for RA (Symmons and Harrison, 2000).

 

Base line predictors of future functional disability in patients with early RA that have been identified in various cohorts include older age, female gender, longer disease duration at presentation, presence of rheumatoid factor, more tender and / or swollen joints and poorer function (Ollier et al, 2001).

 

Base line predictors of future radiological change in patients with early RA that have been identified in various cohorts include older age, female gender, longer disease duration at presentation, presence of rheumatoid factor and more tender and/or swollen joints (Ollier et al, 2001).

 

Impact

 

RA can be a severely disabling disease, but its impact is changing due to advances in the management and use of different therapeutic strategies. However, most data available are with less aggressive approaches towards treatment with less effective therapeutic agents than those currently used.

 

Hakala et al (Hakala et al, 1994) examined the severity of RA in a population study using 1987 ARA criteria and found that about two-thirds of cases had mild or moderate disability due to RA and less than 10% had severe disability. The disability starts early and rises in a linear fashion (Hochberg et al, 1992). Within ten years of onset, at least 50% of patients were unable to hold down a full-time job in older studies (Brooks, 1997) but outcomes have improved over recent years with new disease modifying drugs, better pain management and joint replacement surgery.

 

Although there is no cure for RA, long term disability can be reduced with current therapies. Modern treatment is effective at controlling disease activity and reducing long-term disability, whilst early treatment aimed at controlling disease activity is the present strategy to prevent this disability (European Commission (2004): European Action Towards Better Musculoskeletal Health). Physiotherapy and adaptations to the home may also reduce disability. It has been recently estimated that, with current management applied optimally, the burden of disability due to RA might be further reduced by 25% in developed countries.

 

Co-morbidities and mortality

 

RA is associated to reduced life expectancy. Mortality is generally greater in studies reporting patients in the clinic setting who usually suffer from a more severe form of the disease. Mortality is related to severity of RA as expressed by functional status, health status and health status perception, radiological damage and extra-articular manifestations (Naz and Symmons, 2007). Co-morbidity, especially cardiovascular disease and hypertension; formal education; socio-economic and marital status, but not race, may also affect survival.

 

Economic impact

 

The direct and indirect cost of illness are twice as high in people with RA compared to controls (Birnbaum et al, 2000). The direct costs are typically between 25 and 50% of the total (Woolf, 2008). Direct costs are high during the first 2 years, largely related to consultations; then they fall and then gradually increase over the subsequent years due to the costs of devices, adaptations and arthroplasty which contribute to 40% of the total costs after 10 years (Hulsemann et al, 2005). These costs are strongly influenced by inpatient care and admission rates which vary within and between countries. The costs of medication have been found to be less than 20% of direct costs in earlier studies but this has increased considerably with the widespread use of anti-TNF (Woolf, 2008).

 

Future trends

 

Future changes in the incidence and prevalence of RA are difficult to predict. Recent studies indicate a decline in its prevalence, particularly among women (Spector et al, 1993). On the other side, RA is expected to increase in the next 10 years in Europe due to the ageing populations. The net result of these opposite trends, however, is unpredictable and prospective figures should be collected through specific studies.

 

Osteoporosis and low trauma fractures

 

Definition

 

Osteoporosis is defined as a systemic skeletal disease characterized by a low bone mass and a microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. In 1994 a WHO expert panel (WHO Technical Report No 843, 1994) operationalized this concept by defining diagnostic criteria for osteoporosis on the basis of measurement of bone mineral density (BMD). The risk of fracture rises when the bone mineral density (BMD) declines, and the WHO operationalized this concept by considering osteoporosis to be present when the BMD level in women was 2.5 standard deviations or more below the normal mean for young women.

 

The International Osteoporosis Foundation has recommended that, for the purposes of diagnosis as opposed to those of assessment, BMD should be measured at the hip using dual-energy X-ray absorptiometry. This brought to the following values:

 

Osteoporosis: a BMD value at least 2.5 standard deviations below the mean BMD of young adult women (BMD Tscore ≤ –2.5).

 

Osteopenia (low bone mass): a BMD value between 1 and 2.5 standard deviations below the mean BMD of young adult women (–2.5 <BMD Tscore <1).

 

Clinically, osteoporosis is recognized by the occurrence of characteristic low-trauma fractures, the best documented of these being hip, vertebral and distal forearm fractures.

 

Natural history

 

A classical case of osteoporosis may be present in a woman about 55 years of age with a wrist fracture. Ten years later she may present back pain, with or without minor trauma, and thoracolumbar spine X-rays may show a vertebral fracture. She might have one of several risk factors: low body weight, premature menopause, a family history of fractures, smoking, heavy alcohol consumption, inactivity, calcium or vitamin D deficiency or corticosteroid use. The back pain may remit and relapse with subsequent vertebral fractures. Approximately 1015 years later, at the age of 7580, she may fall and sustain a hip fracture, resulting in hospitalisation, a 20% excess risk of death, considerable functional impairment and possibly a loss of independence if she survives. Although this scenario is instantly recognizable, osteoporosis may present any of a wide range of fractures and at a variety of ages; it is also increasingly recognized among men.

 

Incidence

 

The incidence of osteoporosis is best measured indirectly as the incidence of fractures resulting from the condition. The lifetime risk or the 10 year probability of fracture can also be considered (van Staa et al, 2001). The lifetime risk of fragility fractures at the age of 50 or more is considerable (Table 5.6.7).

 

Table 5.6.7. Estimated lifetime risks of fractures in the UK at various ages

 

In Western populations the incidence of hip fractures strongly increases with age, with rates of 2/100,000 person-years in women aged under 35,rising to 3032/100,000 person-years in women 85 years of age and older, with rates in men of 4 and 1909 respectively (Cooper and Melton, 1992). Above 50 years of age there is a female to male incidence ratio of approximately 2:1 (EULAR Online Course, 2008). The highest incidence rates have been reported from Northern Europe (EULAR Online Course, 2008).

 

Overall, about 98% of hip fractures occur among people aged 35 or more, 80% of which occur in women (due in part to the presence of more elderly women than men). In Europe it has been estimated that in 2000 there were 178,777 hip fractures sustained by men over 50, and 711.223 by women over 50 (Kanis and Johnell, 2005).

 

Most distal forearm fractures occur in women (the age-adjusted female to male ratio being 4:1), and around 50% occur in women aged 65 or more. A multicentre study in the United Kingdom found annual incidences of 9 and 37 per 10 000 men and women respectively, with hospitalization rates of 23% and 19% respectively (ONeill et al, 2001). There was a tendency for the incidence rate of distal forearm fracture to continue to increase after the age of 70 among women, perhaps pointing to increasing frailty in the elderly female population of Western countries throughout the last decade of the twentieth century and the first decade of the twenty-first.

 

Most fractures in subjects aged over 50 are the result of osteoporosis. The incidence rates of proximal humeral, pelvic and proximal tibial fractures also rise steeply with age and are greater in women than in men. About 80% of proximal humeral fractures occur in individuals aged 35 or more, three-quarters of which occur in women. Similar patterns have been observed for distal femur fracture and fractures of the rib, clavicle and scapula (Woolf and Pfleger, 2003).

 

5.6.3.4.4 Prevalence

 

Prevalence is best measured by the frequency of reduced BMD or numbers of those with vertebral deformity.

 

The prevalence of vertebral deformity increases with age and is present in one in eight men and women aged over 50 in Europe. The rates vary between populations with a demonstrated three-fold variation across Europe and up to two-fold variation within European countries in the EVOS study (ONeill et al, 2001). Vertebral deformities in men at the earlier ages may represent developmental changes rather than fractures. The age-adjusted and sex-adjusted incidence rates for vertebral deformity are 1% per year among women and 0.6% per year among men from the European Prospective Osteoporosis Study (European Prospective Osteoporosis Study, 2002). Similar figures have been found also in the USA.

 

It is estimated that around 23% of women aged 50 or more in the United Kingdom have osteoporosis at any site as defined by WHO (WHO Technical Report 919, 2003). There is a steep increase in the proportion that has osteoporosis between 50 and 80 years of age.

 

On the basis of the IOF criteria, the general prevalence of osteoporosis rises from 5% in women at the age of 50 to 50% at the age of 85, whilst in men the comparable figures are 2.4% and 20%, respectively (Kanis et al, 2000)

 

Determinants, risk factors and the population at risk

 

Apart from age and female gender, the major determinants of fracture are falling, low bone mass, i.e. osteoporosis, and previous low trauma fracture. There are risk factors that identify those more likely to fall (Table 5.6.8) and those who may have osteoporosis or be at risk of fracture (Table 5.6.9). There are some semi-independent risk factors for fracture such as bone turnover as assessed by bone markers. Frailty and co-morbidity are also risk factors for poor outcome of fracture (Woolf and Akesson, 2003).

 

Most hip fractures occur after a fall in men or women with reduced bone strength. The risk of falling increases with age. Hip fracture may also occur spontaneously (Melton, 1995).

 

Table 5.6.8. Risk Factors for Falling in the Elderly

 

Table 5.6.9. Risk factors for bone loss, development of osteoporosis and for fracture in the elderly (excluding falls)

 

Bone density has the strongest relationship with fracture but many fractures will also occur in women without osteoporosis. The possibility of fracture increases when combining low bone density with the presence of other risk factors for fracture. In particular, bone density combined with risk factors that are at least partly independent of bone density (Cummings et al, 1995) can identify those at much increased risk of fracture but the exact interaction of different risk factors has not yet been established. Efforts are being made to use existing data to describe the absolute risk for the individual patient over a time period that is comprehensible, i.e. 5 to 10 years (Kanis et al, 2002) (Table 5.6.10).

 

Table 5.6.10. Estimated 10 year risks of fractures in the UK at various ages

 

Disability

 

Hip fracture results in pain, loss of mobility and excess mortality. Nearly all are hospitalised and most undergo surgical repair of the fracture or replacement of the joint. At 1 year, hip fracture is associated with 20% mortality or 50% loss of function, with only 30% regaining all prior functions (Melton, 2003; Sernbo and Johnell, 1993). Many lose their independence and require long-term care. Only half those surviving a hip fracture will walk again and often not to the same level as prior to the fracture (Magaziner et al, 1990; Sernbo and Johnell, 1993).

 

Acute vertebral fracture affects one’s quality of life with limitation of activities and restriction of participation. Up to a fifth are hospitalised and some will require subsequent long-term care, especially those of advanced age or with comorbidity. Pain and loss of spinal movement cause most limitations. Chronic vertebral osteoporosis, with progressive compression fractures and deformities, is associated to pain and long-term impairment of quality of life which worsens with each new vertebral fracture. The effect is not just due to the recent fracture as it has been demonstrated several years after the fracture. Physical performance declines even in the absence of significant pain, whilst undiagnosed vertebral fractures are associated with disability. Co-morbidity is common at this advanced age and contributes to the impact on quality of life and increased mortality (Woolf and Akesson, 2006).

 

Colle’s fracture results in hospitalisation rates of 23% of men and 19% of women (ONeill et al, 2001; Sernbo and Johnell, 1993). Only 50% report a good functional outcome at 6 months (Kaukonen et al, 1988; Sernbo and Johnell, 1993).

 

Mortality

 

Mortality following hip fracture is high in the first year, perhaps up to 25% in women and 35% in men (Cooper, 1997; Sernbo and Johnell, 1993). Comorbidity is an important contributory factor in hip fractures and a determinant of outcome (Cooper, 1997; Sernbo and Johnell, 1993).

 

Vertebral fractures are also associated with an increased mortality at 5 years as seen with hip fracture, but this is gradual over the 5 year period. No excess mortality is associated with wrist fractures (Center et al, 1999; Cooper et al, 1993; Johnell et al, 2004).

 

Future trends

 

The number of osteoporotic fractures is increasing throughout Europe, and the number of hip fractures is projected to more than double from 2000 to 2050. This is due to the ageing of the population and changes in risk factors (Report on osteoporosis in the European Community 1998).

 

Low Back pain

 

Definition

 

Low back pain is a major health and socio-economic problem in Western countries. Many people will experience one or more episodes of low back pain in their lives. It is usually defined as pain localised below the line of the 12th rib and above the inferior gluteal folds (Anderson, 1986), with or without leg pain. It is usually classified as beingspecific” or “non-specific”. Specific back pain is defined as symptoms caused by a specific pathophysiologic mechanism such as prolapsed intervertebral disc, infection, spondyloarthropathy, fracture or tumour. Such specific causes account for about 10% of cases whereas 90% of people with low back pain have no clearly defined pathophysiologic cause.

 

Non-specific low back pain is usually classified according to duration and recurrence. Acute back pain is of less than 6 weeks duration; subacute is between 6 weeks and 3 months duration and chronic when it lasts more than 3 months (Frymoyer, 1988). Frequent episodes are described as recurrent back pain.

 

Natural history

 

Most episodes of low back pain settle after a couple of weeks but many have a recurrent course with further acute episodes affecting 2044% within 1 year in the working population and lifetime recurrences of up to 85% (Andersson, 1999). Frequently it never fully resolves and is characterised by exacerbations of chronic low back pain. Many people with chronic low back pain also have widespread pain.

 

Incidence

 

There are not many studies of incidence but a large study from the Netherlands reported an incidence of 28.0 episodes / 1000 people per year; the incidence of low back pain with sciatica was 11.6 / 1000 people per year, affecting men a little more than women, more frequent in the working population and higher between 25 and 64 years of age (van den Velden et al, 1991). New episodes are twice as common if there is a history of previous low back pain.

 

Prevalence

 

Lifetime prevalence varies between 58% and 84%. Back pain is very common but the prevalence varies according to the definitions used and the population studied. Non-comparability of surveys makes it difficult to understand whether there are real differences between countries. Point prevalence (proportion of population studied that are suffering back pain at a particular point in time) is between 4% and 33% (Woolf and Pfleger, 2003).

 

Determinants, risk factors and the population at risk

 

The occurrence of low back pain is associated with age, physical fitness, smoking, excess body weight and strength of back and abdominal muscles. Psychological factors associated to the occurrence of back pain are anxiety, depression, emotional instability and pain behaviour. Occupational factors clearly play a role such as heavy work, lifting, bending, twisting, pulling and pushing as well as psychological workplace variables, such as dissatisfaction. Obesity is a risk factor for chronicity.

 

Psychosocial aspects of health and work combined with economic aspects have an impact on work loss attributed to back pain more than physical aspects of disability and physical requirements of the job.

 

Impact on individual (morbidity, mortality) and on society (socioeconomic)

 

Back pain has a marked effect on the individual and also on society due to its frequency and economic consequences of work loss and social support.

 

The problem is defined by pain, which is often persistent during the episode with many that do not have complete resolution of their symptoms and have flares on a background of chronic pain. Pain is often worse with prolonged walking, standing and sitting - which restricts mobility - as well as travelling any distance in a vehicle. Sleep is often disturbed and some also have chronic widespread pain. Strenuous activities as well as leisure pursuits may be prevented during the episode of back pain by worsening of the pain and after the episode by fear of recurrence.

 

Most return to work within 1 week with 90% returning within 2 months (Woolf and Pfleger, 2003), but the longer on sick leave, the less likely the person is to return to work. After 6 months off work, less than 50% will return to work and after 2 years absence, there is little chance of returning. Because of this aspect and its frequency, the costs to society are enormous. About 90% of the cost of back pain is indirect due to work loss and disablement reflecting its frequency among the working population (European guidelines for prevention in low back pain http://www.backpaineurope.org/web/files/WG3_Guidelines.pdf). The costs are mainly incurred by 1025% of those with back pain persisting for more than 1 month. In cases with chronic back pain, the impact on health and low frequency of return to work probably reflects that about 50% of cases are associated to a non-specific widespread pain condition.

 

Future trends

 

There has been a reported increase in prevalence in the UK between 1980 and 2000 (Palmer et al, 2000), but this is interpreted as related to a greater awareness of minor back symptoms and willingness to report them. Such cultural changes could lead to an enormous increase in the burden.