Journal of Public Health | Vol. 39, No. 3, pp. 429–432 | doi:10.
1093/pubmed/fdx105
Guest Editorial
A new public health, tiered approach
to improving musculoskeletal health
through physical activity provision
One of the most frequent requests of public health by pol-
icymakers is for a rational approach to setting priorities. In
the past this led naturally to an analysis of the common
causes of avoidable mortality. Death rates were and are avail-
able, relatively reliable and easily comparable over time and
geography. Mortality statistics are also good for identifying
and tracking inequalities and who would argue against the
importance of reducing premature mortality? In the current
era, however, premature mortality has reduced so much that
a mortality based approach to priority setting is no longer fit
for purpose. Lifespan has increased more rapidly than
‘healthspan’, leading to a worldwide epidemic of non-fatal
poor health. It is the nature of this epidemic that now needs
to drive the priorities for an effective response.
Our ability to compress morbidity has not kept up with
our ability to extend life.1 This is a particular tragedy because
most people are likely to favour preserved quality of life in
old age and a good death over an extended period of ill
health at the end of life. Sir Richard Doll used to say his aim
was ‘to die young as old as possible’. From the perspective
of governments and service providers this situation also
represents a nightmare scenario of expanding costs and
volumes of care at a time of fiscal restriction. The need and
demand for health and care services is increasingly driven
not so much by the incidence of common causes of death
but by the prevalence of multi-morbidity and loss of inde-
pendence. Public health professionals need an approach to
identifying priorities that reflects this shift. Their advice on
allocation of resources needs to recognize the significance of
the problem based upon its true burden and the value of
interventions taking into account the full range of benefits
to the population and to public services. Under such an
approach, musculoskeletal conditions, the subject of this art-
icle, are bound to feature high on any list as policy priorities,
along with conditions such as sensory deficit, incontinence
and dementia.
Musculoskeletal conditions fall broadly into three groups.2
In inflammatory conditions, such as rheumatoid arthritis, the
immune system attacks and damages the joints and spine,
generally requiring urgent, intensive specialist treatment to
© The Author 2017. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
suppress the immune system to prevent lifelong pain and
disability. These rarer conditions affect 1–2% of the popula-
tion, and their public health importance emerges from the
very high impact on those affected (for example, one in
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/39/3/429/4103127 by guest on 25 July 2020
three people with rheumatoid arthritis is no longer working
within 2 years of diagnosis).3 The cost to the NHS of effect-
ive therapies is also substantial and rising: in 2015–16, three
of the most commonly used biologics in rheumatoid arthritis
were among the top five drugs positively appraised by
NICE with greatest overall cost: adalimumab £416.6 m, eta-
nercept £230.6 m and rituximab £155.9 m.4
Osteoarthritis of the hip or knee and back or neck pain
are conditions of musculoskeletal pain that affect around 10
million people in the UK to a varying degree, with higher
prevalence and severity among older people and those with
high BMI. These conditions are the greatest cause of pain
and disability, and are managed mainly through self-care and
primary care. A substantial minority of those with osteoarth-
ritis will have joint replacement surgery at some stage: in
2015, the National Joint Registry recorded over 200 000 hip
and knee replacements, over 90% due to osteoarthritis.5
The final group is osteoporosis, the silent and painless
weakening of bones, and the fragility fractures that can result
without significant trauma: for example, a fall from standing
height onto a carpeted floor. Fragility fractures affect around
300 000 people annually in the UK, causing pain and loss of
independence. This is particularly true for hip fractures
which each year in the UK account for 85 000 unplanned
admissions, 1.8 million bed-days, and cost the NHS an esti-
mated at £1.9 billion.6
The prevalence and impact of almost all musculoskeletal
conditions increases with rising age. For example, a third of
people aged 45 years and over live with osteoarthritis, rising
to a half of those aged over 75 years.7 Along with conditions
such as dementia, musculoskeletal conditions become very
common and almost universal among the oldest age groups.
Unlike dementia, however, musculoskeletal conditions also
substantially affect the working age population. A third of
people with osteoarthritis retire early, give up work or reduce
the hours they work because of their condition.8
High quality data, and particularly comparative data, on
population musculoskeletal health are hard to obtain.9
Furthermore, traditional approaches to epidemiology are not
429
430 GUEST EDITORIAL
well suited to understanding the impact of living with mul-
tiple long-term conditions. Poor musculoskeletal health is a
common contributor to multi-morbidity and its impact
needs to be recognized in ways that go beyond documenting
incidence and prevalence. Conversely, many well-established
public health interventions, such as those aimed at tackling
obesity and physical inactivity, affect multiple pathological
and degenerative processes and are among the most effect-
ive ways of improving musculoskeletal health especially at
the population level.10
The benefits of physical activity in this context are now
well recognized11,12 and are described in a recent joint report
from Arthritis Research UK, Public Health England, NHS
England and the Department of Health, entitled: ‘Providing
physical activity interventions for people with musculoskeletal
conditions’.13 The report recognizes that determinants of
poor musculoskeletal health are complex and multifactorial,
and like other non-communicable diseases are associated with
deprivation.14 If society is to take a public health approach to
improving musculoskeletal health, then interventions targeted
only at those most affected will not address the need. There
needs to be a concerted effort to provide and promote the
interventions which will shift health behaviours for the much
larger numbers of people at low and moderate risk.
Fig. 1 Commissioning physical activity provision for people with musculoskeletal conditions.
The report is a landmark in this area and presents a new,
tiered, public health approach towards musculoskeletal
health and to promoting and supporting physical activity
for people with musculoskeletal conditions (see Fig. 1). It
summarizes the evidence and tackles the widespread mis-
conception that little can be done about musculoskeletal
conditions, and that poor musculoskeletal health is an inev-
itable—or even acceptable—consequence of ageing. It
recognizes that while good musculoskeletal health is a
strong driver for generic physical activity programmes, peo-
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/39/3/429/4103127 by guest on 25 July 2020
ple with pain and limitation from musculoskeletal condi-
tions initially require specific approaches to build joint
strength and stability in order to participate. Following an
evidence review, one structured community rehabilitation
programme, ESCAPE-pain, is highlighted as likely to be of
particular benefit.15 The report emphasizes the importance
of removing structural barriers to physical activity for peo-
ple with musculoskeletal conditions, ensuring that existing
provision meets the needs of people with musculoskeletal
conditions by being accessible, well-designed and appropri-
ately promoted.
The aim here is not to develop whole new physical activ-
ity programmes and systems for people with musculoskeletal
conditions. Part of the attractiveness of this approach is that

the benefits of physical activity are so widely felt, particularly
for people living with multimorbidity. Some of these wider
benefits will be characterized in a dedicated return on invest-
ment model currently being developed by Public Health
England. This will report not only on the financial cost-
effectiveness and cost-utility, but will deal with wider societal
costs including productivity. Some local authorities have
now begun to include specific aspects of musculoskeletal
health in their physical activity programmes, for example in
the Rotherham ‘Active for Health’ programme which has
reduced symptoms and improved physical activity participa-
tion for people with low back pain.16
In response to the report, public health teams who recog-
nize the need to do more to promote musculoskeletal health
in the populations they serve could now act by doing the
following:
– Review planning documents such as joint strategic needs
assessments to ensure that the musculoskeletal health
needs of local populations have been characterized.
– Use the tool kit included in the report to review and
map existing physical activity provision and pro-
grammes, identifying any gaps in support for people
with musculoskeletal conditions.
– Ensure physical activity plans such as those in joint
health and wellbeing strategies, recognize and meet the
needs of people with musculoskeletal conditions.
– Ensure that people participating in physical activity pro-
grammes are asked about their musculoskeletal health
and any changes measured, for example using the
Musculoskeletal Health Questionnaire (MSK-HQ).
– Include the impact of musculoskeletal health, and steps
taken to reduce it, in annual reports.
– Capture and share examples of good practice in physical
activity provision for people with musculoskeletal
conditions.
While there are still some important research questions to
be addressed, and indeed this area should be a priority for
research funding as well, the existing evidence and scale of
the problem are clearly sufficient to justify local action. One
of the roles in which local government-based public health
teams can excel is in making the case for interventions that
address the wider determinants of health and where benefits
accrue across sectors. This report is both a stimulus and
strong endorsement for maintaining and strengthening exist-
ing generic physical activity plans, while making a compelling
case for reviewing these to ensure the particular needs of
people with existing musculoskeletal conditions are met.
GUEST EDITORIAL 431
Benjamin M. Ellis1, John N. Newton2
1
Imperial College Healthcare NHS Trust, London, and Arthritis
Research UK, Chesterfield, UK
2
University of Manchester and Public Health England, London,
UK
Address for correspondence to Benjamin Ellis, Arthritis Research
UK, Copeman House, St Mary’s Court, St Mary’s Gate,
Chesterfield S41 7TD, UK, E-mail: b.ellis@arthritisresearchuk.org
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/39/3/429/4103127 by guest on 25 July 2020
References
1 GBD 2015. Disease and Injury Incidence and Prevalence
Collaborators. Global, regional, and national incidence, prevalence,
and years lived with disability for 310 diseases and injuries,
1990–2015: a systematic analysis for the Global Burden of Disease
Study 2015. Lancet 2016;388(10053):1545–1602.
2 Ellis B, Silman A. Raising the profile of musculoskeletal disorders
with governments. Rheumatology (Oxford) 2013;52(11):1929–30.
3 Barrett EM, Scott DG, Wiles NJ et al. The impact of rheumatoid
arthritis on employment status in the early years of disease: a UK
community-based study. Rheumatology (Oxford) 2000;39(12):
1403–9.
4 NHS Digital. Prescribing Costs in Hospitals and the Community,
England 2015/16. November 22, 2016
5 National Joint Registry for England, Wales, Northern Ireland and
Isle of Man (2016). 13th Annual Report. Part two including data on
clinical activity online at www.njrreports.org.uk
6 British Orthopaedic Association/British Geriatric Society. The Care
of Patients with Fragility Fracture. London: British Orthopaedic
Association, 2007.
7 Arthritis Research UK: Osteoarthritis in General Practice. February
2013.
8 Arthritis Care. OA Nation. 2012.
9 Davies SC, Fowler T, McKee M. On the state of public health in
England. Lancet 2012;380(9856):1793–5.
10 Clark PM, Ellis BM. A public health approach to musculoskeletal
health. Best Pract Res Clin Rheumatol 2014;28(3):517–32.
11 Low back pain and sciatica in over 16s: assessment and manage-
ment [Internet]. National Institute for Health and Care Excellence.
2016. Available from: https://www.nice.org.uk/guidance/ng59 (13
June 2017, date last accessed).
12 Osteoarthritis: care and management [Internet]. National Institute
for Health and Care Excellence. 2014. Available from: https://
www.nice.org.uk/guidance/CG177 (13 June 2017, date last
accessed).
13 Providing physical activity interventions for people with musculo-
skeletal conditions [Internet]. Arthritis Research UK, Public Health
England, NHS England, Department of Health. Arthritis Research UK.
2017 Available from: http://www.arthritisresearchuk.org/policy-and-
public-affairs/reports-and-resources/reports/physical-activity-report.
aspx (13 June 2017, date last accessed).
432 GUEST EDITORIAL
14 Bridges S. Chronic pain. Available from: http://content.digital.nhs.
uk/catalogue/PUB09300/HSE2011-Ch9-Chronic-Pain.pdf (13 June
2017, date last accessed).
15 Hurley MV, Walsh NE, Mitchell H et al. Long-term outcomes and
costs of an integrated rehabilitation program for chronic knee pain:
a pragmatic, cluster randomized, controlled trial. Arthritis Care Res
(Hoboken) 2012;64(2):238–47.
16 Frith G, Copeland RJ, Roden A et al. (2017). Evaluation of Active For
Health [poster presentation].The International Society of Behavioural
Nutrition and Physical Activity Conference, Victoria, Canada.
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/39/3/429/4103127 by guest on 25 July 2020