Chapter II

Review of Related Literature

2.1 Musculoskeletal Conditions

The World Health Organizations described musculoskeletal conditions, comprising of over than

150 diagnoses, as symptoms that affect the normal range of motion of an individual; these

conditions may involve the muscles, bones, joints and associated tissues such as tendons and

ligaments. As listed in the International Classification of Diseases Symptoms, these conditions are

typically characterized by pain and limitations in mobility, dexterity and functional ability, often

reducing people’s capacity to work and their ability to participate in social roles having impacts

on the mental wellbeing of the individual and at a broader level, the prosperity and progress of

communities.

In accord to WHO, the most common and disabling conditions of the musculoskeletal system are

osteoarthritis, back and neck pain, fractures correlated to bone fragility, injuries and systemic

inflammatory conditions. Through life-course conditions of the musculoskeletal system are

prevalent and commonly affects people those of adolescence to of older ages. The prevalence and

impact of these conditions are forecasted to rise as the global population ages and risk factors for

noncommunicable diseases increases, particularly affecting low and middle-income settings.

Musculoskeletal conditions occur commonly with other noncommunicable diseases in

multimorbidity health states. With these conditions affecting the regular locomotor movement of
an individual, it is justifiable that these conditions account for the greatest portion of dropped

productivity in the workplace. In 2011, according to the American Academy of Orthopedic

Surgeons, musculoskeletal conditions cost the United States about $13 billion or 1.4% of the total

Gross Domestic Product.

According to the Global Burden Disease 2017 study, musculoskeletal conditions were the highest

contributor to global disability, approximately accounting for 16% of all years lived with disability.

Lower back pain is found as the leading cause of disability since it was first measured in 1990.

While the prevalence of musculoskeletal conditions varies by age and diagnosis, between 20%–

33% of people across the globe live with a painful musculoskeletal condition.

In accord to the GBD 2017, burden of disease profiles is shifting from communicable, neonatal,

maternal and nutritional health conditions to predominantly long-term noncommunicable diseases,

commonly including musculoskeletal conditions. To give a comparison, noncommunicable

diseases accounted for 61.4% of global disability-adjusted life years (DALYs) in 2016, compared

to 43.9% in 1990. The steepest trajectory of rise in the burden of such diseases was observed in

low-income settings. With this transition in health profiles, the global population is now living

longer with consequences of chronic disease and injuries, particularly musculoskeletal conditions.

This demographic shift underlines the importance of re-focusing the emphasis of health care from

curative to promotive, preventive and rehabilitative health care, particularly in low- and middle-

income settings. This is also relevant in high-income settings, where over-medicalization and an
emphasis on a biomedical, rather than biopsychosocial approach to care, can lead to poor or

adverse health outcomes and unsustainable health care expenditure. According to Carvallo

Araulio, the opioid medicine epidemic for management of non-cancer pain, the majority of which

is of musculoskeletal etiology, is a notable example. Prioritizing community and primary health-

care services and a long-term care system will have the greatest impact on improving functional

ability into older age and containing health care expenditure.

The 2016 Global Burden of Disease (GBD) data for noncommunicable diseases identified the

profound burden of disease associated with musculoskeletal health. DALYs for musculoskeletal

conditions increased by 61.6% between 1990 and 2016, with an increase of 19.6% between 2006

and 2016. Osteoarthritis was observed to have a 104.9% rise in DALYs (or 8.8% when age-

standardized) from 1990 to 2016. Musculoskeletal conditions comprised the second highest global

volume of years lived with disability in 2016. Spinal pain remains the leading cause of global

disability since 1990. Notably, these GBD estimates likely underestimate the true burden of

musculoskeletal health conditions since important constructs such as carer burden, participation

and financial implications are not considered.

According to Barnett K, Mercer, more than half of all older people experience multimorbidity of

noncommunicable diseases. Such multi-morbidities increase with age and are more common

among those in lower socioeconomic groups. This reinforces the need to address

noncommunicable diseases in a whole-person, integrated manner rather than with an approach

where individual conditions are managed in silos. Multimorbidity very commonly includes
musculoskeletal conditions, with musculoskeletal prevalence ranging from one-third to more than

one-half of all noncommunicable disease multimorbidity presentations. Importantly, the presence

of a musculoskeletal condition significantly depletes physical function, clusters with mental health

impairment and increases health-care costs. These data highlight that policies, strategies and health

programmes for noncommunicable diseases, as well as essential care packages for universal health

coverage (UHC), must include musculoskeletal health as an integral component, particularly those

programmes targeted in lower socioeconomic settings and for older people.

The sustainable development goals (SDGs) and the Decade of Healthy Ageing 2020–2030 offer a

timely and favorable opportunity for increased global attention and action on musculoskeletal

health. To achieve the 2030 agenda for sustainable development and to promote and maintain

health across the life course, a renewed and sustained focus on improving musculoskeletal health

is needed at national and global levels. While the Bone and Joint Decade 2000–2010 catalysed

awareness of the burden of musculoskeletal health conditions, important gaps in health system

improvements remain and a significant proportion of the global population continues to live with

disabling musculoskeletal conditions, irrespective of age, race and geography.

Three priorities for action to reduce the global disability burden exist. First, there are substantial

opportunities for global leadership to support policy responses which have so far been neglected.

For example, the 2008–2013 Action plan for the global strategy for the prevention and control of

noncommunicable diseases focused on mortality associated with cardiovascular disease, cancer,

diabetes and chronic respiratory disease, rather than on strategies to promote living with improved
intrinsic capacity. While the nine global targets within the Global action plan for the prevention

and control of noncommunicable diseases 2013–2020 are relevant to the prevention and

management of musculoskeletal health conditions, musculoskeletal health is not identified as a

priority area for noncommunicable disease management and important occupational and

environmental targets are not considered. Musculoskeletal health was only included as a

noncommunicable disease target since 2016 in the Action plan for the prevention and control of

noncommunicable diseases in the WHO European Region. The World Health Organization and its

Member States can help reduce the global disability burden through an increased focus on

musculoskeletal health within system-reform initiatives for noncommunicable diseases and

healthy ageing policy agendas. There is a wealth of evidence for what works to improve

musculoskeletal health outcomes, yet translation into policy and practice remains limited. Explicit

advocacy for, and integration of, musculoskeletal health and persistent pain into existing global

and/or regional policy reform initiatives will be important to drive appropriate policy and service

implementation, particularly as part of action towards the SDGs.

Second, targets and monitoring for functional ability should be set as part of noncommunicable

diseases global health surveillance and as part of the health SDG performance targets. SDG 3 aims

to ensure healthy lives and promote wellbeing for all at all ages, which implies support for

functional independence and participation. However, the specific target for noncommunicable

diseases remains focused on reducing premature mortality from such diseases by one-third by

2030. This target is critical because premature mortality from such diseases disproportionally

affects people in low- and middle-income countries, the poorest and most vulnerable; however,

targets to reduce disability related to noncommunicable diseases, as the major contributor to global
DALYs, are absent. While musculoskeletal health conditions may be indirectly addressed as part

of the SDG on health, particularly in the context of preventive actions that influence comorbidities

such as obesity, current performance targets would not reflect changes in musculoskeletal-related

disability. Global targets should also be set to reflect maintenance of mobility, participation and

physical function as key components of functional ability and performance.

Third, musculoskeletal health should be part of noncommunicable diseases national policy reform.

National system-level health policy and strategy responses to address musculoskeletal health as a

component of noncommunicable diseases care remain disproportionate with the burden of

disease. While health systems are now responding to the burden of noncommunicable diseases,

there has been an almost exclusive focus on cancer, diabetes, chronic respiratory disease and

cardiovascular disease and, more recently, mental health.

While these foci are important, inadequate prioritization of musculoskeletal health and persistent

pain as part of health reform initiatives targeting noncommunicable diseases does not align with

contemporary evidence for global health, limiting opportunities for development of appropriate

integrated policy responses, workforce capacity building initiatives and harnessing of capacity in

civil society. System reform leadership in some high-, middle- and low-income regions is

nonetheless encouraging. For example, the development of person-centered models of care for

musculoskeletal health and persistent pain that consider multimorbidity and care integration across

the health and social care systems are recognized to improve policy capacity, service delivery and
cost–effectiveness. Implementation strategies have been developed for high-, middle- and low-

income settings.

A global framework to develop, implement and evaluate such models has also been

established. Further development and dissemination of effective models of care is needed to

inform promotive, preventive, rehabilitative and curative essential packages for UHC; innovative

service delivery options; and strategies to build workforce capacity and consumers’ capacity to

actively participate in care.

Service- and system-level responses addressing musculoskeletal health should also integrate the

responses to other noncommunicable diseases. This will have the greatest impact if organizations

that focus on noncommunicable diseases and injury work cooperatively to tackle the crosscutting

challenges of health system reform.

2.1.1 Musculoskeletal Conditions and Disorders in Asian Countries

According to Bitsiosis A., reported data all over the world showcases that nurses have a

very high prevalence of MSDs, to give context, in Europe, from 10% to 50% in France ,

89% in Portugal, and 85% in Macedonia; in the Americas, from 35.1% to 47% in USA and

from 32.8% to 57.1% in Brazil in Africa, 80.8% in Uganda; and in our Asia, 78.6% in

China, 85% in Saudi Arabia, and 88% in Iran. (Global Burden Disease 2010)
In Vietnam, although the occupational health sector is still underdeveloped, occupational

diseases and their prevention are increasingly concerned. Currently, the list of occupational

diseases covered by insurance has expanded to 34. However, MSDs are not included in

this list. Many occupational disease prevention programs have been implemented in

different work environments, including the medical milieu. Contrariwise, there was only

one recent and unique study ever about MSDs among workers in the health sector in

Vietnam in 2015 that showed a prevalence of MSDs over the past twelve months among

nurses at Viettiep hospital, the largest provincial hospital in Haiphong in the northern

coastal region of Vietnam, which was very high (81%), and many related factors may have

affected these disorders. This suggests that the problem of MSDs among nurses in Vietnam

can be very large. However, in order to have a comprehensive picture of MSDs among

nurses, this study is to assess the current status and risk factors affecting MSDs among

nurses at the district hospitals of Haiphong.

Numerous previously studies throughout the world have shown the very different

prevalence of MSDs on nurses over a 12-month period. This result was relatively similar

to the other studies on nursing such as 79.5% in Turkey, 76% in India 76.2% in long-term

study from 2004 to 2010 in 3915 nurses in Taiwan, 70% in Poland, 78% in Nigeria, and

79.5% in China. However, this result was lower than those observed in Uganda in 2013

among 755 nurses (80,8%), in Estonia (84%), 89% in Portugal, in Macedonia (85%), and
80.8% in Uganda and, in our Asia, there were Saudi Arabia (85%), Iran (88%), and Japan

(85.5%).

The most common site affected in this study was the lower back (44.4%) and the neck

(44.1%). The results of some studies in Asia are comparable to this result; for example, in

Pakistan in 2015, it was illustrated that around 49.7% of nurses faced MSDs in their

lumbar, and 35.4% of them complained about MSDs in their shoulders; another study in

Iran and in Hong Kong saw the same picture with 40% and 42%, respectively, of nurses

reporting MSDs in their lumbar; and one study in Nigeria (in Africa) showed that the rate

of MSDs in lower back was 44.1%. Although most studies have shown that lower back

was the most common site, this prevalence was still modest when compared to that from

other studies in Asia: in Japan (lower back 71.3%), in Iran (73.2% in 2010 and 65.3% in

2014), in China (64.83%), and in Saudi Arabia (65.7%); and this was similar to other

studies in Europe: in Portugal (60.9% in 2015 and 63.1% in 2017) and in Slovenia (85.9%).

Neck was also one of the most common sites of MSDs. Results in this study are similar to

those of some other studies such as 46.3% in Iran, 42.8% in China, and 48.94% in Malaysia.

2.1.2 Disabilities in The Philippines

Results of the National Disability Prevalence Survey (NDPS) showed that, in 2016, around

12 percent of the Filipinos age 15 and older experienced severe disability Almost one in

every two (47%) experienced moderate disability while 23 percent with mild disability.

Almost one-fifth (19%) experienced no disability. In this survey, the disability prevalence
rate corresponds to the percentage of persons with severe disability. Almost a third of

population age 60 and older experience severe disability the percentage of persons age less

than 60 who experienced mild disability is 23 percent to 25 percent. More than one in two

persons (53% to 54%) age at least 40 experienced moderate disability. Almost one in every

three persons (32%) with severe disability belonged to the older population age group of

60 and older.

The Philippines ratified the United Nations Convention on the Rights of Persons with

Disabilities (CRPD) in 2008, and several laws and policies to promote the rights of people

with disabilities have been enacted. However, a study commissioned by Disability Rights

Promotion International (DRPI) and the National Federation of Organizations of people

with disabilities in the Philippines (Katipunan ng Maykapansanan sa Pilipinas, Inc.,

KAMPI) in 2008, found that a number of the rights of people with disabilities were

regularly violated. The study interviewed people with disabilities from Metro Manila, and

the Luzon, Mindanao, and Visayas island groups. The authors highlighted that despite

having several policies and laws to protect their rights, people with disabilities often faced

discrimination in educational and employment settings, and experienced barriers to social

participation and access to health and rehabilitation services. The study recommended a set

of immediate measures to eliminate barriers to participation and for the economic

empowerment of people with disabilities. However, socioeconomic factors associated with

disability and the level of access to services and participation in the community compared

to people without disability were not studied

Results of the National Disability Prevalence Survey (NDPS) showed that, in 2016, around

12 percent of the Filipinos age 15 and older experienced severe disability. Almost one in

every two (47%) experienced moderate disability while 23 percent with mild disability.

Almost one-fifth (19%) experienced no disability. In this survey, the disability prevalence

rate corresponds to the percentage of persons with severe disability. Almost a third of

population age 60 and older experience severe disability the percentage of persons age less

than 60 who experienced mild disability is 23 percent to 25 percent. More than one in two

persons (53% to 54%) age at least 40 experienced moderate disability. Almost one in every

three persons (32%) with severe disability belonged to the older population age group of

60 and older.

2.1.2 Musculoskeletal Conditions and Disorders in The Philippines

According to the Philippine Statistic Authority the total cases of occupational diseases in

establishments reached 125,973 in 2015. This is comparatively lower by 26.7 percent than

the reported cases in 2013. Among industries, 13 out of the 18 major industries nationwide

reported varying levels of declines in the number of cases of occupational diseases in 2015.

The biggest decrease (81.3%) was recorded in mining and quarrying from 9,255 in 2013

down to 1,735 in 2015.

On the other hand, the number of occupational diseases grew the most in real estate

activities which increased by 189.6 percent from 240 cases in 2013 to 695 in 2013. The

distribution of occupational diseases across industries in 2015 showed that administrative

and support service activities (34.3% or 43,183) and manufacturing industry (31.1% or

39,143) jointly comprised almost two thirds (65.4%) of the total cases of occupational

diseases during the year. Meanwhile, industries which posted least shares of occupational

diseases included: water supply, sewerage, waste management and remediation activities

(0.4%); arts, entertainment and recreation (0.3%); and repair of computers and personal

and household goods, and other personal service activities (0.3%).

Cases of Occupational Diseases PSA stated that call center activities posted the highest

share of occupational diseases under administrative and support services industry

Noteworthy, call center activities (voice) exceeded all other sub-sectors in the

administrative and support services industry on the number of cases of occupational

diseases in 2015 at 31,270. This is equivalent to almost one-fourth (24.8 percent) of the

total cases which means that 1 out of every 4 cases of total occupational diseases in the

industry originated from this sub-sector.

Specifically, the six occupational diseases with the highest incidences in the call center

activities (voice) subsector were as follows: back pain (23.8% or 7,428); occupational lung

disease (16.8% or 5,266); occupational asthma (13.8% or 4,305); other work-related

musculoskeletal diseases (12.0% or 3,745); neck-shoulder pain (10.9% or 3,410); and

essential hypertension. This may be attributed on the nature of work in the sector mostly

characterized by mental and emotional stress brought about by frequent repetitive tasks

coupled with prolonged sitting and lengthy verbal communication with clients.

1 out of every 3 (32.8%) occupational diseases reported in 2015 were back pains. Back

pain is highest in industries involving manual labor such as in manufacturing (34.3% or

14,185 cases) and those that require sitting for long periods of time like that in

administrative and support service activities (25.6% or 10,581 cases) majority of which

involve call center activities. Cases of Occupational Diseases by Type in Call Center

Activities (Voice), Philippines: 2015 Cases of Occupational Diseases Number Percent

Share Call Center Activities (Voice) 31,270, Back Pain 7,428, Occupational Lung Disease

5,266, Occupational Asthma 4,305, Other Work-Related Musculoskeletal Diseases 3,745,

Neck-Shoulder Pain 3,410, Essential Hypertension 3,124 10.0 Other occupational diseases

3,992. Aside from back pains, also included in the top five occupational diseases in 2015
 were essential hypertension (11.5% or 14,539); neck and shoulder pain (11.4% or 14,392);

other work-related musculoskeletal diseases (7.7%)

2.1.3 Economic Implications of MCs/ MCDs in The Philippines

2.1.3 Social Implications of MCs/ MCDs in The Philippines

2.2 Rehabilitation

Rehabilitation according S no. 624 in standardizing Physical Rehabilitation Centers is a branch of

medicine which deals with the prevention, diagnosis, treatment and rehabilitation of

neuromusculoskeletal, cardiovascular, pulmonary and other system disorders which produce

temporary or permanent disability in patients as well as the performance of different diagnostic

procedures, including, but not limited to, electromyography and other electro diagnostic

techniques. It also involves specialized medical care and training of patients with loss of function

so that one may regain their maximum potential, physically, psychologically, social and
vocationally with special attention to prevent unnecessary complications or deterioration and to

assist in physiologic adaptation to disability.

Rehabilitation measures target body functions and structures, activities and participation,

environmental factors, and personal factors. They contribute to a person achieving and maintaining

optimal functioning in interaction with their environment, using the following broad outcomes:

prevention of the loss of function slowing the rate of loss of function improvement or restoration

of function compensation for lost function maintenance of current function. Rehabilitation

outcomes are the benefits and changes in the functioning of an individual over time that are

attributable to a single measure or set of measures. Traditionally, rehabilitation outcome measures

have focused on the individual’s impairment level. More recently, outcomes measurement has

been extended to include individual activity and participation outcomes. Measurements of activity

and participation outcomes assess the individual’s performance across a range of areas; including

communication, mobility, self-care, education, work and employment, and quality of life. Activity

and participation outcomes may also be measured for programmes. Examples include the number

of people who remain in or return to their home or community, independent living rates, return-

to-work rates, and hours spent in leisure and recreational pursuits. Rehabilitation outcomes may

also be measured through changes in resource us, reducing the hours needed each week for support

and assistance services.

Rehabilitation is an allied medical profession which develops, coordinated and utilizes selected

knowledge and skill in planning, organizing, directing and evaluating the programs for the care of
individuals whose ability to function is impaired or threatened by disease or injury. Physical

Therapy is the art and science of treatment by means of therapeutic exercises, heat, cold, light,

water, manual manipulation, electricity and other physical agents. The goal of physical therapy is

to help the patient reach maximum potential.

Physiotherapy will help an individual to adapt a place in society while learning to live within limits

of his capabilities. Physical Therapy requires in depth knowledge on human growth and

development, human anatomy and physiology, neuroanatomy and neurophysiology, biomechanics

of motion, manifestations of disease and trauma, normal and abnormal psychological responses to

injury, sickness and disability, and the cultural socioeconomic influences of the individ

2.2.1 Physical Rehabilitation in the Philippines

In the Philippines, rehabilitation services are limited, particularly in the public

(government-funded) health sector and are mainly found in major cities in Level 3

hospitals.6 Most specialists, particularly physiatrists, practice in the National Capital

Region

Rehabilitation, as defined for the scope of this paper, is a set of measures that assist

individuals with disabilities, both pre-existing and new, to achieve and maintain optimal

body function in interaction with their environment. Nationwide in 2011, there were 305

729 low-income households with members having disabilities. Region 8, the area most
 affected by Typhoon Haiyan, had 13 478 low-income households in which people with

disabilities lived. Following Typhoon Haiyan in November 2013, all six hospitals in

Tacloban City, the capital of Leyte province, that previously offered rehabilitation services

were devastated. The entire physical therapy unit of the Eastern Visayas Regional Medical

Center (regional hospital) was flooded, most of the therapeutic equipment was destroyed

and medical records were water damaged. Shops that sold assistive devices (standard

orthopedic wheelchairs, crutches, walkers and canes) were also damaged. Like the rest of

the people of Tacloban City, hospital and health personnel were also victims of the disaster.

Immediately after Haiyan, all services, including rehabilitation services for people with

disabilities and injuries ceased at both in and out-patient facilities. Some limited services

resumed a few weeks after the disaster with the help of local and international volunteers

and the establishment of temporary facilities such as field hospitals.

2.3 Rehabilitation Centers

2.3.1 Rehabilitation Centers/ Facilities in the Philippines

2.3.2 Strategies for Community Inclusion

2.4 Problems in Implementation for the Disabled

2.5 Mall Concept on Health Facilities

2.6 Architectural Healing Space

According to Brian Schaller, the environment is concretely defined as “the place”, and the things

which occur there “take place”. The place is not so simple as the locality, but comprises of concrete

things which have physical substance, shape, texture, and color, and together join to form the

environment’s personality, or setting. It is this setting which allows certain spaces, with similar or

even matching purposes, to embody very diverse properties, in accord with the unique cultural and

environmental situations of the place which they exist (Bachelard). Phenomenology is considered

as a “return to things”, maneuvering away from the abstractions of science and its unbiased

objectivity. Phenomenology engages the concept of partiality, making the thing and its unique

conversations with its place the pertinent topic and not the object itself. The man-made constituents

of the setting become the settlements of opposing scales, some large - like cities, and some small

- like the house. The trails between these settlements and the many features which make the

cultural environment develop the secondary defining characteristics of the place. The difference

of natural and manmade offers one the principal stage in the phenomenological approach. The

second is to succeed inside and outside, or the connection of earth-sky. The third and final step is

to measure character, or how things are complete and occur as participants in their environment

(Palasmaa,).

The placebo effect is known as a “fake treatment” that does not hold any active substances itself.

It helps the body heal simply by the mind’s expectation that it will heal, and the brain then releases

endorphins. Placebos can ultimately reduce swelling and pain, minimizing stress, which makes the
body better able to receive medical treatments. Charles Jencks made full use of the architectural

placebo effect, and through his work shows the importance of environments of healing.

Architecture has the power to indirectly boost the immune system. He used this philosophy to

guide his design of the Maggie’s Centres, a series of retreat centres for people dealing with cancer.

There, people receive practical and social support for dealing with cancer in an environment that

supports their emotional needs. William James, an American philosopher and psychologist,

believed “the greatest revolution in our generation is the discovery that human beings, by changing

the inner attitudes of their minds, can change the outer aspects of their lives.”

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Senate n. 624 Introduced by Manuel Villar