Rheumatology Advance Access originally published online on February 3, 2006
Rheumatology 2006 45(3):248-249; doi:10.1093/rheumatology/kei275
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EDITORIAL |
The relationships of musculoskeletal disease to age, pain, poverty and behaviour
MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
Correspondence to: p.dieppe{at}bristol.ac.uk
In a recent letter to the editor of Rheumatology I pointed out that the Bone and Joint Decade is just one of several current decades of action trying to improve world health, including the decades of health in ageing; pain control and research; the eradication of poverty; and behaviour in health-care [1]. I suggested that, as the agendas of each of these four other decades is highly relevant to bone and joint disease, we needed some joined-up thinking. So, what are the relationships between age, pain, poverty, behaviour and musculoskeletal problems, and what other issues should be added to the list?
Age is obvious. The incidence of many major musculoskeletal diseases, such as osteoarthritis and osteoporosis, is age-related, and in older people bone and joint diseases are the major cause of the very high prevalence of chronic pain and physical disability [2]. However, we do need to gain a better understanding of age and its influence on bones and joints, and we need to differentiate between chronological age, biological age and social ageing. Pain too is clearly important, as it is the symptom of most significance to the majority of people with bone and joint problems. But, as with age, our understanding of its cause and control in bone and joint disease is poor, and we have not yet put it as high on our agenda as it is on that of our patients. For example, we try to measure pain severity, but it is pain distress that leads to health-seeking behaviour and the need for interventions.
The importance of poverty may be less obvious. In the UK poverty is relative—there are big gaps between those who have great wealth and the most disadvantaged in society—but serious poverty of the sort seen in some other countries is uncommon. So we study socio-economic status as a proxy for relative poverty. There has been a lot of work highlighting the relationships between socio-economic status and mortality, including recent, worrying data to show that the gap between rich and poor, and hence health and lifespan inequalities, continues to widen in the UK [3]. Much less data exists on associations between socio-economic status and chronic conditions such as common bone and joint disorders. However, a recent survey of these relationships in eight European countries showed that self-reported arthritis, osteoarthritis and back complaints were all strongly related to socio-economic status (using education as the indicator) [4]. In addition, as outlined below, there is a wealth of data to suggest that those who are worst off in our society are less likely to obtain appropriate service provision for severe musculoskeletal problems, in spite of our social welfare and NHS.
Behaviour is, in my view, the key to understanding the causes and management of most of the chronic bone and joint disorders. The musculoskeletal system is designed to allow us freedom of movement within our gravitationally challenged world. Its biomechanical properties are critical, and the use and abuse we make of it is the cause of many of our problems. Therefore, our behaviour is the reason that we get so many aches and pains and such a lot of problems with locomotor disability, particularly in later life. Similarly, the way to relief of these difficulties is through altered behaviour, both by patients and by health-care professionals. Our health behaviours are dependent on culture and attitudes in society, as well as our perceptions of self, and these differ in the various groups within our increasingly diverse, multicultural societies. And, as pointed out already, deciding to seek help from health-care professionals such as readers of this journal is a type of behaviour. Those readers may be interested to hear that a UK society of behavioural medicine has just been formed, with the objective of bringing behavioural issues and research to the forefront of our efforts to combat chronic disease [5].
There are at least three other issues that we should consider alongside age, pain, poverty and behaviour. They are sex, ethnicity and rural living. Sex (and/or gender) influences the incidence, prevalence, outcomes and care of many chronic rheumatic conditions, and sex is clearly interrelated with age (as more older people are women than men) and with socio-economic status. Race and ethnicity are more complex but no less important problems in our increasingly multicultural society; their interrelationships with socio-economic status remain an issue for the UK. Finally, whether you live in an urban or rural setting can influence not only your access to good health-care, but also your exposure to environmental factors that might influence the development of musculoskeletal problems; and urban or rural living has clear interactions with socio-economic status. In a recent HTA (Health Technology Assessment) report, my group highlighted the complex interrelationships between age, sex, ethnicity and socio-economics in relation to inclusion in health research, describing these factors, along with the variations in disease expression, as a ‘web of diversity’ [6]. Similarly, there are a large number of overlapping sociodemographic factors that will influence whether people get musculoskeletal problems, as well as the chances that they have of accessing good health-care for them, as shown in Fig. 1.
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An exploration of recent literature on the provision of joint replacement suggests that these determinants of social exclusion influence the behaviour of health professionals when it comes to the provision of care for people with severe musculoskeletal pain.
Total hip or knee joint replacements are common, effective interventions for severe joint disease, and their utilization is increasing in the UK [7]. But we have a number of problems with provision, not least of which is the fact that there are no clear indications for total joint replacement (TJR). As we do not know who to operate on or when to intervene in the course of chronic joint disease, there is plenty of scope for inequities in provision. Recent data from the UK and Canada indicate that such inequities exist: women, older people and poorer people are less likely to receive a TJR than younger men and those at the top end of the socio-economic ladder, in spite of the fact that the former group have the greater need [7–13]. And it is unlikely that joint replacement is an isolated example of inequities in the provision of good care for those with musculoskeletal disease. We have unpublished data to suggest the same trends exist with other orthopaedic procedures, as well as with access to other services for joint problems, including aids and appliances, drugs and physiotherapy.
Why do these inequities in provision exist? The answers are not known, and they are probably both complex and embedded in our culture, which is clearly an ageist one when it comes to health-care [14]. Access to services and variations in perceptions of the value of health-care professionals, as well as willingness to undergo an intervention, can all operate on the patient's side of the equation [13]. As for us professionals, the worry is that we too may be unknowingly operating in an ageist, sexist, ‘poorist’ fashion as we go about our daily business.
Good management of bone and joint diseases is dependent on the behaviour of people in pain, as well as that of those that they may seek help from. There is evidence that at present, in spite of greater need, women, older people and the most marginalized people in our society are less likely to receive optimal care than affluent, middle-aged, white males. If we believe in equity we should be embracing the objectives of the decades that seek better understanding of pain and behaviour in health-care, and the eradication of poverty, as well as the narrower focus of the Bone and Joint Decade.
The author has declared no conflicts of interest.
References
- Dieppe P. Too many decades or too little joined up thinking? Rheumatology 2006; In press.
- Woolf AD, Akesson K. Understanding the burden of musculoskeletal conditions. BMJ 2001;322:1079–80.
[Free Full Text] - Shaw M, Davey Smith G, Dorling D. Health inequalities and New Labour: how the promises compare with real progress. BMJ 2005;330:1016–21.
[Free Full Text] - Dalustra J, Kunst A, Borrell C et al. Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries. Int J Epidemiol 2005;34:316–26.
[Abstract/Free Full Text] - The UK Society for Behavioural Medicine. Available at: www.uksbm.org.uk
- Bartlett C, Doyal L, Ebrahim S, Davey P, Bachmann M, Egger M, Dieppe P. The causes and effects of socio-demographic exclusions from clinical trials. Health Technol Assess 2005;38:1–168.
- Dixon T, Shaw M, Ebrahim S, Dieppe P. Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need. Ann Rheum Dis 2004;63:825–30.
[Abstract/Free Full Text] - Juni P, Dieppe P, Donovan J, Peters T et al. Population requirement for primary knee replacement surgery: a cross-sectional study. Rheumatology 2003;42:516–21.
[Abstract/Free Full Text] - Sanders C, Donovan JL, Dieppe PA. Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee. Rheumatology 2004;43:353–7.
[Abstract/Free Full Text] - Yong P, Milner P, Payne J, Lewis P, Jennison C. Inequalities in access to knee joint replacements for people in need. Ann Rheum Dis 2004;63:1483–9.
[Abstract/Free Full Text] - Milner P, Payne J, Stanfield R, Lewis P, Jennison C, Saul C. Inequalities in accessing hip joint replacement for people in need. Eur J Public Health 2004;14:58–62.
[Abstract/Free Full Text] - Hawker G, Wright JG, Coyte PC et al. Differences between men and women in the rate of use of hip and knee arthropolasty. N Eng J Med 2000;342:1016–22.
[Abstract/Free Full Text] - Hawker GA, Wright JG, Glazier RH et al. The effect of education and income on need and willingness to undergo total joint arthroplasty. Arthritis Rheum 2002;46:3331–9.[CrossRef][Web of Science][Medline]
- Williams A, Evans JG. Rationing health care by age. BMJ 1997;314:820–5.
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