Best Practice & Research Clinical Rheumatology

Vol. 22, No. 4, pp. 759–772, 2008

doi:10.1016/j.berh.2008.07.003
available online at http://www.sciencedirect.com

11

Prevention of musculoskeletal conditions in

the developing world

Anthony D. Woolf * BSc, MBBS, FRCP

Professor
Institute of Health Research, Peninsula Medical School, Universities of Exeter and Plymouth, UK
Duke of Cornwall Department of Rheumatology, Royal Cornwall Hospital, Truro, TR1 3LJ, UK

Peter Brooks FRACP, FAFRM, FAFPHM

Professor, Executive Dean
Faculty of Health Sciences, The University of Queensland, Australia

Kristina Åkesson MD, PhD

Professor
Department of Clinical Sciences, Lund University, and Department of Orthopaedics, Malmö University Hospital,
Sweden

Girish M. Mody MBChB (Natal), FRCP (London), MD (Cape Town), FCP (SA)
Professor, Fellow of the University of Kwa Zulu-Natal, and Aaron Beare Family Professor of Rheumatology
Nelson R Mandela School of Medicine, College of Health Sciences, University of Kwa Zulu-Natal, Durban, South
Africa

Musculoskeletal conditions are an increasingly common problem across the globe due to in-
creased longevity and increased exposure to risk factors such as obesity and lack of physical
activity. The increase is predicted to be greatest in developing countries, and there is thus an
urgent need for the implementation of strategies and policies that will prevent and control
these conditions. The ideal is modification of the risk factors in the whole community, and
this will have wide-ranging health benefits as these risk factors are common to other major
conditions. Changing people’s behaviour is a challenge; targeting those at highest risk is

* Corresponding author. Duke of Cornwall Department of Rheumatology, Royal Cornwall Hospital, Truro,
TR1 3LJ, UK.
E-mail address: anthony.woolf@btopenworld.com (A.D. Woolf).
1521-6942/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
760 A. D. Woolf et al

potentially more effective, providing that there are both affordable ways of identifying those at
risk and affordable interventions. Early intervention in those with a condition such as rheuma-
toid arthritis is probably the most cost-effective approach, but requires diagnostic capacity – in
clinical skills and/or technology – as well as access to care. There is now much evidence for
what can be achieved, but the challenge is how to implement these different strategies in de-
veloping countries where there are competing priorities for limited resources. The key strat-
egy is to raise awareness among the public, health professionals, and policy makers of the
importance of musculoskeletal health, of what can be achieved by prevention and treatment,
and to ensure that policies reflect this. It is also necessary to educate the public to know when
to seek care, and health-care workers to recognize the early signs of musculoskeletal
conditions.

Key words: prevention; musculoskeletal; developing countries; health policy; primary

prevention; management.

Musculoskeletal conditions are common across the globe. Their prevalence is pre-
dicted to increase greatly, particularly in developing countries. This will be predom-
inantly due to the increase in the population at risk through increased longevity, and
to increased exposure to the determinants of musculoskeletal conditions such as
obesity and lack of physical activity. Subsequently there is an urgent need to develop
and implement strategies and policies that will prevent and control these conditions.
This large and increasing burden of musculoskeletal conditions has been recognized
by the UN and WHO by their endorsement of the ‘Bone and Joint Decade’.1 How-
ever, this is not yet reflected in the global strategy of the WHO for the prevention
and control of non-communicable disease2, since this strategy focuses on conditions
with fatal outcomes. However, the need for action has been recognized in the Euro-
pean strategy of the WHO for non-communicable diseases3, where musculoskeletal
conditions rank 8 as a cause of disability-adjusted life years (DALYs). Global priorities
will change as it is appreciated that the successful reduction of fatal outcomes from
both communicable and non-communicable diseases will lead to an increase in the
burden due to non-fatal but disabling conditions, of which musculoskeletal conditions
are the commonest. This will result in the increasing dependency of the aging pop-
ulation on their societies through physical disability. This large and growing burden
justifies action to prevent and control these conditions cost-effectively, but can
this be achieved? There have been great advances in recent years in successfully de-
veloping effective but increasingly expensive interventions to control musculoskeletal
conditions such as rheumatoid arthritis using anti-tumour necrosis factor (TNF)
therapy and osteoporosis with bisphosphonates and parathyroid hormone (PTH).
These are being used in the established market economies of developed countries,
but they are of limited relevance in economies where the intervention costs are
many times the GDP. As another example, joint replacement is a highly successful
intervention for osteoarthritis, but there is little equity of access across the globe.
We therefore need to think about what strategies are realistic for preventing and
controlling musculoskeletal conditions in developing countries, and this will be dis-
cussed further.
There are many issues to consider. What conditions are important in developing
countries? What are the determinants for their occurrence and outcome? What
are the trends and why? What are the principles of prevention and control? What
are the interventions that we can use, and how can strategies for prevention and con-
trol be implemented?
 Prevention of MSK conditions 761

WHAT MUSCULOSKELETAL CONDITIONS ARE CURRENTLY

IMPORTANT IN DEVELOPING COUNTRIES, AND
WHAT ARE THE TRENDS?

The spectrum of musculoskeletal conditions in less-developed countries is generally

similar to that in developed countries, except that severity may be worse because of
late presentation and lack of effective treatment, and impact may be greater because
of the environment in which the person is living. There are some conditions which
have a different geographic and socioeconomic distribution, such as infections – in
particular tuberculosis (TB) and HIV – and bone conditions such as Paget’s disease
and osteomalacia. The burden of musculoskeletal conditions was recently estimated
for developing and developed regions of the world (Table 1).4,5 The differences re-
late to the population sizes in developing countries, the greater longevity in devel-
oped countries, and the differences in access to treatment resulting in higher
disability rates in developing countries. The burden will change largely due to in-
creased life expectancy in developing countries, as musculoskeletal conditions are
often lifelong.
The major problems are joint diseases (osteoarthritis and rheumatoid arthritis, re-
active arthritis, and gout), back pain, osteoporosis and other bone diseases, and
trauma and injuries.6 Infections and congenital and developmental problems are
more common in developing countries.
Joint problems are common universally. Osteoarthritis is the most common joint
condition, and causes significant disability. In most cases it is age-related, and its prev-
alence is increasing globally. It may be secondary to joint trauma, and injuries are a ma-
jor problem in developing countries. Rheumatoid arthritis occurs in all populations,

Table 1. Estimated burden of musculoskeletal diseases, by gender and by developed or developing

regions, 2001.5
Total Males Females Developing regions Developed regions
(both genders) (both genders)
Numbers of DALYs
(thousands):
Rheumatoid arthritis 4757 1353 3404 3238 1520
Osteoarthritis 16,372 6621 9750 11,049 5323
Other musculoskeletal diseases 8699 5033 3638 6789 1880
All musculoskeletal diseases 29,798 13,007 16,792 21,076 8723
Percentage of total DALYs:
Rheumatoid arthritis 0.32 0.18 0.49 0.27 0.59
Osteoarthritis 1.12 0.86 1.39 0.91 2.05
Other musculoskeletal diseases 0.59 0.65 0.52 0.56 0.73
All musculoskeletal diseases 2.03 1.69 2.4 1.74 3.37
Percentage of
musculoskeletal DALYs:
Rheumatoid arthritis 15.96 10.4 20.27 15.36 17.42
Osteoarthritis 54.94 50.91 58.07 52.43 61.02
Other musculoskeletal diseases 29.1 38.69 21.66 32.21 21.56
DALY, disability-adjusted life year. Note: totals may not add up due to rounding.
762 A. D. Woolf et al

although prevalence has been found to vary between populations.6 It has the same po-
tential outcomes, with a high risk of major disability if not treated. Much remains un-
diagnosed and inadequately treated in developing countries due to limited health-care
services, lack of access to expensive treatments, and inadequate medical education.
Clinical presentation can be very late, limiting the treatment options. Gout is universal,
but appears to be more common in certain populations from COPCORD studies,
such as in Indonesia and in Australian aboriginals and New Zealand Maoris.7–10
Lack of treatment results in chronic destructive disease with consequent disability,
a rarity now in developed countries. Reactive arthritis is seen in all countries, with in-
cidence related to the prevalence of HLA-B27 in the population. Exposure to triggers
of chlamydia and gastrointestinal infections is greater in developing countries. Septic
arthritis, TB, and infections related to HIV/AIDS are also more common in
developing countries. HIV is associated with a wide spectrum of musculoskeletal
conditions.
Infections of joints, bone and soft tissue are common in developing countries. TB is
now often antibiotic-resistant. HIV is associated with a wide spectrum of musculoskel-
etal conditions and has a high prevalence in developing countries.
Back pain is universal, from COPCORD and other surveys, but its socioeconomic
impact is greatly influenced by social support systems and social norms. Of all back
pain worldwide, 37% is attributable to work.2,11 In developed countries back pain is
one of the commonest causes of sick leave and early retirement, but this is not at
present the situation in developing countries where the social structure does not so
easily support people with impaired function due to back pain. Using the WHO
International Classification of Functioning, Disability and Health model12, despite
limited function and activities because of back pain, people still participate because
of environmental contextual factors. These describe the physical, social and attitu-
dinal environment in which people live and conduct their lives; for example, society’s
views that the need to work and support the family overrides any difficulties because
of back pain.
Osteoporosis and fragility fractures are largely age-related due to reduced bone
strength and increasing risk of falling. They occur in all societies, but will increase
with aging of the population.13 The greatest increase is likely to occur in developing
countries, where it is predicted to become a major public health problem. Rickets
and osteomalacia, now seldom seen in developed countries except in people who
avoid sunlight exposure, is still a problem in many countries around the globe; this
is due to lack of exposure to adequate sunlight not being compensated for by adequate
dietary vitamin D intake.
Musculoskeletal trauma and injuries are an increasing problem. As examples, lower-
limb injuries often result in limited mobility, upper-limb injuries result in loss of dex-
terity, and neck and back injuries result in chronic pain. Road traffic accidents
(RTAs) are sometimes fatal, but the commonest long-term non-fatal outcomes relate
to musculoskeletal problems. RTAs increase dramatically with developing economies:
more cars, better roads, inadequate driving skills, and poor safety measures. This in-
crease in RTAs and associated mortality and morbidity has led to a UN resolution to
improve road safety. Injuries consequent to non-accidental violence and wars also
need to be considered.
Work-related musculoskeletal problems are also common, but the frequency is not of-
ten documented in developing countries as there is no routine data capture through
social security systems. About 70% of developing countries’ economically active pop-
ulation works in agriculture, and increasing industrialization exposes others also to the
 Prevention of MSK conditions 763

risk of injuries. Worldwide, 37% of all back pain is attributable to work.11 There is also
a range of other musculoskeletal work-related disorders affecting arms, legs or hands,
such as tendonitis, tenosynovitis, or carpal tunnel syndrome. Sports injuries are com-
mon in all populations. Work-related and sports-related injuries will increase with in-
creasing industrialization and wealth. The impact of work-related musculoskeletal
disorders will also increase as workers’ expectations change.
Congenital and developmental problems – such as congenital dysplasia of the hip or
club foot – are more common problems in later life because of failure to identify
and treat early.

WHAT ARE THE DETERMINANTS OF MUSCULOSKELETAL

PROBLEMS AND CONDITIONS?

The determinants for the occurrence and outcome of musculoskeletal conditions are
similar in all populations, although the exposure to these varies. These determinants
include obesity, lack of physical activity, poor diets (including lack of calcium and vita-
min D), smoking, alcohol, injuries such as through RTAs, sports or violence, repetitive
work-related activity, and diseases and infections. The access to health, social and ed-
ucational interventions or availability of safety measures will also determine outcomes
(Table 2). Changes in these determinants are being seen in developing countries.
Obesity is on the increase. WHO’s latest projections14 indicate that, globally, ap-
proximately 1.6 billion adults (age 15 years) were overweight, and at least 400 mil-
lion adults were obese in 2005, and this will increase to approximately 2.3 billion adults
overweight and more than 700 million obese by 2015. Globally, at least 20 million chil-
dren under the age of 5 years were overweight in 2005. This was considered a problem
only in high-income countries, but overweight and obesity are now increasing dramat-
ically in low- and middle-income countries, particularly in urban settings. Reasons in-
clude a global shift in diet towards increased intake of energy-dense foods that are high
in fat and sugars but low in vitamins, minerals and other micronutrients, and a trend
towards decreased physical activity due to the increasingly sedentary nature of many
forms of work, changing modes of transportation, and increasing urbanization.

Table 2. Major determinants of musculoskeletal health.

Conditions and problems Personal intrinsic Personal extrinsic Environmental
Osteoarthritis Age Housing Natural environment
Rheumatoid arthritis Gender Work type Human-made physical
Osteoporosis Genetics Personal environment
Back pain Diet transport Pollution: sanitation,
Musculoskeletal trauma BMI water, air
and injuries Alcohol Personal support
Infections Smoking and assistance
Congenital and developmental Exercise Health, social
conditions Co-morbidities educational systems
Education Health, social
Psychological assets educational interventions

BMI, body mass index.

764 A. D. Woolf et al

Lifestyles are becoming increasingly sedentary, with at least 60% of the world’s pop-
ulation failing to complete the recommended amount of physical activity required to
induce health benefits.15 Important factors in developing countries are an increase
in sedentary behaviour during occupational and domestic activities, and increasing
use of ‘passive’ modes of transport. Urbanization has resulted in several environmental
factors which may discourage participation in physical activity, such as population over-
crowding, high-density traffic, and lack of parks, sidewalks and sports or recreation fa-
cilities. There are also changes in frame of mind about what is considered a normal
lifestyle.
Calcium and vitamin D are important for bone health, and many people – in partic-
ular the old and frail – have low levels of calcium intake and low levels of vitamin D
through insufficient exposure to sunlight and an inadequate dietary intake to compen-
sate. The extent of the problem in developing countries is unclear, but is likely to be
similar or even greater. This is seen especially in those who remain covered despite
strong sunlight.
Smoking remains an enormous problem for public health. More than 1.1 billion
adults smoked worldwide in 2002, and over 80% of smokers live in low- and mid-
dle-income countries. Smoking is increasing in many of these countries (whereas there
is a decrease in many high-income countries), mostly in men16, although increases are
being seen in young women. Alcohol is also a global problem, although more in some
societies than other17, and is associated with a range of impacts on health, including
musculoskeletal health. Trauma and injuries are also increasing in developing countries
with changes in transportation, urbanization and industrialization.
There is therefore a growing population of people at high risk of, or with, muscu-
loskeletal conditions, many of which will be long-term and progressively disabling,
demonstrating the need for a global strategy to deal with these risk factors. As these
are determinants that are common to many other non-communicable diseases
(Figure 1), there will be mutual benefits from its implementation.

WHAT APPROACHES CAN BE USED TO PREVENT

MUSCULOSKELETAL PROBLEMS AND CONDITIONS?

Prevention can be considered as primary, secondary or tertiary. Primary prevention

avoids the development of a disease. Secondary prevention activities are aimed at early
disease detection, thereby increasing opportunities for interventions to induce remis-
sion or prevent progression of the disease and emergence of symptoms. Tertiary pre-
vention reduces the negative impact of an already established disease by restoring
function and reducing disease-related complications.
Primary prevention can be aimed at the whole population by attempts to modify
a risk factor within the whole population. This requires being able to get the popula-
tion to modify that risk factor, such as keeping physically active. Getting people to
modify their lifestyle without there being a specific reason to motivate them is, how-
ever, challenging. Alternatively, one can take a high-risk approach and identify and tar-
get with an intervention only those who are at greatest risk. This requires knowing the
risk factors and being able to easily identify them in the population in a cost-effective
way, and then to make an effective intervention. Such screening has to be cost-
effective, and there are guidelines to determine when screening is appropriate.19,20
Not only does the condition need to be a significant health problem, but the test
has to be precise, validated, and acceptable to the population. There needs to be an
 Prevention of MSK conditions 765

Figure 1. Interaction of health determinants and various health conditions.18

intervention for people identified through screening that leads to better outcomes
than late treatment and that is accessible. There also needs to be evidence from ran-
domized controlled trials that the screening programme is cost-effective in reducing
morbidity and mortality. A further problem with screening is to then motivate the per-
son who has been identified as at risk to modify their behaviour. As they will poten-
tially have more to gain, they are more likely to concord with any intervention than an
apparently healthy individual who has no identifiable increased risk.
Secondary prevention has the advantage of the person being easier to identify, and
such people are more motivated to concord with any treatment as they are aware of
the symptoms, the cause, and potential outcomes. It has the advantage of preventing –
or at least reducing – the disease sequelae. For example, preventing an osteoporotic
fracture, or preventing joint erosions in RA, with consequent prevention of limitation
of activities and restriction of participation in what the individual needs or wants to do.
Tertiary prevention is equally important, as although the occurrence of the condition
cannot be prevented, its impact can be reduced.
A range of interventions can be used for primary, secondary and tertiary preven-
tion. The aims of intervention are ideally to prevent or control the disease process
or problem, but interventions usually control the symptoms and maximize function.
Primary intervention is usually by modifying lifestyles and environments, and does
not often involve expensive interventions. Secondary and tertiary prevention usually
involves more specific and expensive interventions, which then limits equitable access
in developing countries.
766 A. D. Woolf et al

WHAT INTERVENTIONS CAN BE USED? TREATMENTS AND

STRATEGIES FOR PREVENTION AND TREATMENT

There are now effective treatments for many musculoskeletal conditions, as well as
effective methods to control symptoms and maintain independence. These are not
widely accessible in developing countries, and also not equitably available in developed
countries. In addition, these conditions can be prevented, or their impact reduced, by
dealing with determinants such as obesity, physical inactivity, and accident prevention
programmes. What is needed is a comprehensive approach, and the community-
oriented programmes for control of rheumatic diseases (COPCORD) include not
just assessing the burden but also how to reduce it.21
Considering this in more detail, we need to consider the various interventions and
then strategies for their use. The interventions have been reviewed by the ‘European
Action Towards Better Musculoskeletal Health’ project18,22, and also in the Disease
Control Priorities in Developing Countries Project.5 In the latter study, the cost-
effectiveness of different interventions was also considered.
The aim of prevention is to avoid the condition, but often there is only the oppor-
tunity for secondary prevention, i.e., to control the condition by reducing symptoms
(typically pain and impaired function), and controlling the disease process if possible.
The spectrum of interventions includes information and education, changes in lifestyle
and environment, dietary supplements, pharmacological agents for symptomatic relief
or disease modification, and surgery or rehabilitative interventions. The more inter-
ventional are mostly for secondary and tertiary prevention. Education has a potentially
powerful role in primary prevention but also in later stages of disease management,
where the empowerment of patients enabling them to self-manage has been shown
to be effective.23 It is important that people know how to take responsibility for their
own health3, how to make healthier choices, and follow lifestyle patterns that foster
good health.2
What should we recommend to people in developing countries to minimize their
risks of developing a musculoskeletal problem or to reduce the impact that they have?
These must be feasible and achievable at a population level. We cannot halt the aging of
the population, but there are other trends in determinants of musculoskeletal health
that can be targeted. In Europe, it has been recommended that people of all ages
should be encouraged to follow a ‘bone-and-joint healthy lifestyle’ to avoid the specific
risks related to musculoskeletal health.18 These are relevant to developing as well as
developed countries. They have been developed for each recommendation to have
benefit for several musculoskeletal conditions.24 This means: (1) keeping physically ac-
tive to maintain physical fitness; (2) maintaining an ideal weight; (3) a balanced diet that
provides good nutrition and meets the recommended daily allowance for calcium and
vitamin D; (4) avoidance of smoking; (5) the balanced use of alcohol and avoidance of
alcohol abuse; (6) promotion of accident-prevention programmes for the avoidance of
musculoskeletal injuries; (7) health promotion at the work place; (8) health promotion
related to sports activities for the avoidance of abnormal use and overuse of the mus-
culoskeletal system; and (9) greater public and individual awareness of the problems
that relate to the musculoskeletal system, with good-quality information on what
can be done to prevent or effectively manage these conditions, and the importance
of early assessment. In addition, wound hygiene is important to reduce the risk of mus-
culoskeletal infections. The effectiveness and cost-effectiveness of programmes to en-
courage lifestyle changes are generally not well established5, but there are other
 Prevention of MSK conditions 767

potential benefits. Many of these lifestyle factors are also associated with other (mainly
chronic) conditions, such as heart disease and cancers, and their modification will
therefore have additional health benefits and justify concerted actions for their mod-
ification. There is much health promotion around obesity and the risks of diabetes and
heart disease, but there is little awareness even amongst policy makers that preventing
obesity will benefit musculoskeletal health.25,26
For any recommendation to be implementable, it needs to be specific and have
broad benefits. For an ideal body weight, for example, it is proposed that people of
all ages should maintain their weight so that they are within the recommended healthy
body mass index (BMI) of 19–25 kg/m2.18 Obesity is associated with the development,
progression and symptomatic severity of osteoarthritis of the knee.26 A modest
weight loss is likely to relieve symptoms and delay disease progression of knee
OA.26 Pain in rheumatoid arthritis can be reduced by weight reduction. Severe obesity
may play a part in aggravating a simple low-back problem, and contribute to a long-last-
ing or recurring condition. A low body weight is an established risk factor for osteo-
porosis and for excess mortality following a fracture. Other health benefits will
encourage implementation; avoiding obesity reduces the risk of premature death
from heart disease and of developing diabetes, colon cancer, or high blood pressure,
and helps reduce blood pressure (if elevated). In analyses carried out for the World
Health Report 2002, approximately 58% of diabetes, 21% of ischaemic heart disease,
and 8–42% of certain cancers globally were attributable to a BMI >21 kg/m2.27
Such mutual benefits should also lead to co-promotion of this bone-and-joint
healthy lifestyle concept for the reduction of a range of major non-communicable dis-
eases, provided that there is a consistency of message. However, it is unclear is what
health gain can be achieved, in theory or in practice, by modifying these determinants,
as there are few randomized clinical trial data for these interventions, and little
evidence of how sustainably they can be implemented.
These recommendations are probably equally valid in developing countries, where
the increasing urbanization and other societal changes are affecting levels of physical
activity, diets and other lifestyle factors such as smoking and alcohol. The increase
in injuries and the impact of their sequelae is, however, greater than in developed
countries, more directly visible, and gaining attention.
Targeting high-risk individuals is more effective, in terms of both costs and likeli-
hood of adherence to the intervention. Some individuals are at higher risk than others,
e.g. obese people are more at risk of osteoarthritis and back pain, and underweight
women are more at risk of osteoporosis (Table 3).
The challenge is how to find such individuals in a cost-effective way, and what inter-
vention is appropriate apart from lifestyle changes and surveillance for the earliest
signs of the condition. Checklists have been developed for osteoporosis to help people
recognize if they may be at risk, but then a bone density assessment is needed to con-
firm the level of risk in many people, which limits the application of this approach in
less affluent societies. A WHO fracture risk assessment tool28 has recently been de-
veloped based on various risk factors and BMI or bone density measurement. It has
been developed from population studies conducted predominantly in developed coun-
tries. This limits its use in developing countries, and interventions for osteoporosis are
also expensive. There are no screening tools to identify those at risk for other mus-
culoskeletal conditions, although rheumatoid factor and anti-cyclic citrullinated pep-
tide (CCP) antibodies, along with other factors, carry a high risk of future
development of rheumatoid arthritis29, and those with high uric acid have an increased
risk of developing gout.. However, these approaches cannot be used in case finding.
768 A. D. Woolf et al

Table 3. Individuals at risk of musculoskeletal disease.

Risk factor Condition
Age Over 50 years Osteoarthritis
Over 75 years Osteoporosis and fragility fracture
Gender Women Osteoporosis, RA
Family history RA, OA, osteoporosis
Weight Obese OA, back pain, gout
Underweight Osteoporosis
Nutrition Osteoporosis, osteomalacia, gout
Physical inactivity OA, back pain, osteoporosis
Exercise Injuries
Previous injury Infections, OA, back pain
Biomechanics OA, back pain
Drugs Corticosteroids Osteoporosis
Work place Back pain, injuries

RA, rheumatoid arthritis; OA, osteoarthritis.

Identifying and actively treating people with the earliest features of a musculoskele-
tal condition or problem is probably the most effective specific strategy.18 Early treat-
ment clearly has better results in controlling conditions such as RA30 and in preventing
problems such as low-back pain and regional pain syndrome from becoming chronic.
Early management of trauma produces the best results.
Controlling established musculoskeletal conditions and active rehabilitation will re-
duce the impact, although too late to prevent the problem itself. However, it is at this
stage that many people present to health care in developing counties, and the benefits
of active intervention are well established.18 It is a more costly approach, although the
benefits to the individual can be considerable.
Control of musculoskeletal pain requires education and learning ways of self-man-
agement, including how to cope with the problem but also how to use analgesics ef-
fectively and safely. Weight loss and exercise can also help with pain control. Function
can be improved with symptom and disease control, but also with rehabilitative tech-
niques such as physiotherapy, aids and appliances. This requires access to rehabilitative
services which are limited in the developing world.
Disease management is important, and there is strong evidence that rheumatoid
arthritis can be controlled, with induction of remission in some, and fractures can be
prevented in those with osteoporosis. There are as yet no proven disease-modifying
interventions for OA.

HOW CAN INTERVENTIONS BE IMPLEMENTED – WHAT IS NEEDED?

There are thus various options for the effective prevention and control of musculo-
skeletal conditions, but are they being implemented in any society, yet alone develop-
ing countries? How can implementation be facilitated? Surveys in Europe31 and other
developed countries have shown that people with musculoskeletal pain often choose
to suffer the symptoms and associated disability of a musculoskeletal problem rather
that seek medical interventions. At the individual level there are various reasons for
this, such as the concept that pain should not be masked, treatments may not work
 Prevention of MSK conditions 769

when really needed, and risks may outweigh benefits. There is also a sense that little
can be done for these problems, evidenced by people in all countries, developed and
developing, and alternative treatments are often preferred to conventional ones.
There are also reasons at a societal level. Health-care professionals are inadequately
educated about musculoskeletal conditions, and many are not confident or competent
in assessing the impact that these conditions have on people.32 Policy-makers, when
choosing priorities, predominantly consider diseases with fatal outcomes. Although
the DALY is a summary measure of health, considering all outcomes including morbid-
ity, it will rate highly any condition which is associated with premature death. Years
lived with disability (YLD) gives a clearer measure of the impact on the living, and is
a better indicator of the impact on society of non-fatal conditions.
An analysis of issues affecting implementation were considered in the European Ac-
tion Towards Better Musculoskeletal Health project18, and also have been debated at
a recent international meeting of the Bone and Joint Decade, including a spectrum of
developed and developing countries. There are many factors influencing implementa-
tion, but an overriding one in developed and developing countries is the lack of rec-
ognition by the public, health professionals and policy-makers that these are important
problems that can now be effectively prevented and treated. It is similar to the situ-
ation that cancer was in several years ago when the focus was on palliative care
and not on active, potentially curative therapy, as is now the scenario. There has
been much work over the last 10 years to raise awareness, with the UN- and
WHO-supported Bone and Joint decade and improved data on the burden of these
conditions33, as well as developing an evidence base that they can be effectively pre-
vented and treated both in developed18 and developing countries.5 There is also
a need when considering control of musculoskeletal conditions to consider the con-
text of the person and their roles, needs and expectations along with the local soci-
ety’s attitudes to painful disabling conditions, the expected impact, and who provides
care and support. For example, back pain has a similar prevalence in many parts of the
globe, but the impact varies greatly, being a major cause of sickness benefit and work
loss in westernized societies, whereas in developing countries there is not the expec-
tation of back pain preventing work. However, when it does start having a major eco-
nomic impact because of work loss and the need for social support, either by society
or by family and friends with a consequent impact on their productivity, then priorities
may change.
Implementation requires clear messages that are appropriate for the audience – for
the policy-makers, employers, health professionals, people with musculoskeletal con-
ditions, and the public – and these messages will be different for different generations.
The key messages for the different target groups has been considered by the European
Action Towards Better Musculoskeletal Health.18 When it comes to the message for
the public, we need to think about what is the most relevant advice for them at dif-
ferent stages of their lives in their local environments, and how it relates to other
needs and priorities, some of which may be competing or conflicting. The message
needs to be clear, consistent, and easy to convey. For young people, it is a message
about how to stay active and participate in physical activities for as many years as pos-
sible, but for an older person it is often about how to stay active and independent de-
spite the development of various musculoskeletal problems. However, different
approaches to changing diet and lifestyle factors have been tried34, and it remains
a challenge to alter peoples behaviour. Despite the strength of evidence of the fatal
and non-fatal consequences of smoking, for example, there are still increasing trends
of smoking in many populations and at young ages.
770 A. D. Woolf et al

Implementation is not just about the message, there are other drivers that need to
be considered. Mechanisms that can be used to drive change are educational, organi-
zational, regulatory or financial. Improving public education in general can create
a more positive environment within which to implement specific strategies and be
used to convey specific messages. Against this, there is still advertising for risk factors
to health, such as cigarettes, in many countries. However, advertising can be used ef-
fectively to promote accident prevention, and there have been many hard-hitting cam-
paigns in different countries. Improving professional education is also central, and core
competencies related to musculoskeletal conditions have been defined for all doc-
tors35, and implemented in some countries (including translation into Chinese), but
implementation of these standards needs to be universal. Health systems need to
be organized to give more consideration to chronic disabling conditions, and there
also needs to be better links between health, social care and employment to see
the true impact of chronic disabling conditions and the benefits of effective prevention
and control. Health systems also need to be able to respond to the rapid needs of
trauma to minimize the long-term sequelae. Legislation and regulations at a national
level need to reflect the burden of musculoskeletal conditions in health planning
and provision, and there needs to be appropriate surveillance and information systems
so that policies are informed by accurate information on impact and current evidence
of best practice. Economic drivers are more likely to be effective and can be used to
stimulate changes in public or professional behaviours. Finally, there needs to be
a change in culture, in attitude to one of self-responsibility and recognition of the im-
portance of maintaining one’s musculoskeletal health to ensure independence in an in-
creasingly long life. Against this are the realities of lack of services and resources, and
difficulties of accessing what is available if scarce and spread thinly combined with com-
peting priorities.
There remain many challenges to get musculoskeletal conditions high on the public
health agenda in all countries, but there is now convincing evidence of the importance
of these conditions across the globe, and that there are effective means for their pre-
vention and treatment, many of which are applicable to developing countries.

Practice points

 prevention and effective control of musculoskeletal conditions needs to be

a priority in view of the enormous and growing burden
 people should be encouraged to:
 maintain physical fitness
 maintain an ideal weight
 have a balanced diet that meets the recommended daily allowance for
calcium and vitamin D
 avoid smoking
 have a balanced use of alcohol and avoid alcohol abuse
 societies, in a cultural, socioeconomic and geographic context, should:
 promote accident prevention programmes for the avoidance of musculo-
skeletal injuries
 promote health at the work place and related to sports activities for the
avoidance of abnormal use and overuse of the musculoskeletal system
 Prevention of MSK conditions 771

 promote greater public and individual awareness of the problems that re-
late to the musculoskeletal system, with good-quality information on
what can be done to prevent or effectively manage the conditions, and
the need for early assessment
 provide health-care systems which can identify and treat early those with
significant musculoskeletal conditions and problems

Research agenda

 evidence of efficacy and cost-effectiveness of primary preventative

interventions
 better ways of implementing a bone and joint healthy lifestyle
 better systems of care delivery more suited to developing countries

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