Issue 16 / 2 May 2016

WHILE infectious diseases and the big killers of the disease world dominate the headlines and conversations, the conditions responsible for the greatest health burden are relegated to the background.

According to research conducted on behalf of the World Health Organization, low back pain is responsible for more years lived with disability than any other health condition, ahead of ischaemic heart disease, chronic obstructive pulmonary disease and major depression. Other musculoskeletal conditions come in sixth on this list, and osteoarthritis 11th.

From a societal perspective, the costs associated with these conditions are also staggering. Treating arthritis and musculoskeletal conditions consumes billions from the public health care budget annually; they are one of the most common reasons for accessing health care, and they are the leading health-related cause for people exiting the workforce. Musculoskeletal problems are prevalent from adolescence through to old age, and the burden is likely to increase as the Australian population gets older.

Given the extent, cost and impact of the problem, adequate funding for clinical research and ensuring optimal service delivery should be high priorities. Unfortunately, both areas are being neglected.

In 2014, Bourne and colleagues published a study in the MJA which described the proportion of funding the National Health and Medical Research Council (NHMRC) allocated to research on musculoskeletal conditions. The authors found that trials investigating musculoskeletal conditions attracted 5% of the funding distributed by the NHMRC over the period from 2009 to 2013. To put this figure in context, these conditions are responsible for approximately 27% of the disability burden in Australia. Of further concern, musculoskeletal pain is associated with other risk factors for poor health, such as obesity, smoking and mental health problems.

Neither lack of capacity, nor research targets are responsible for this mismatch. Australia boasts some of the world’s leaders in musculoskeletal research whose work is published in the largest international medical journals.

And there are numerous, well-acknowledged gaps in our understanding of musculoskeletal conditions, perhaps best typified by the example of low back pain.

At present, around 85% of the people who present for care with back pain are given the descriptive diagnosis of “non-specific” or “idiopathic” low back pain. While good quality clinical research has been responsible for some advances in treatment over the past 2 to 3 decades, at present we know more about what not to do for these patients, than what to do, and available treatments are only modestly effective.

Problems with service delivery are evident across the health system. Surveys of primary care practitioners have revealed discrepancies between beliefs and attitudes of clinicians and the best evidence as summarised in practice guidelines. Of even greater concern, practice audit in primary care has shown that patients frequently receive inappropriate and unnecessary diagnostic tests and treatments.

The situation in tertiary care is similarly alarming. Patients with non-specific pain are commonly referred for consultation with surgical specialists, despite the fact that surgery is rarely indicated. This results in waiting times that can stretch into years, during which these patients commonly receive no treatment for their condition or comorbidities.

What can be done about the situation?

In 2012, the federal government established the National Mental Health Commission in recognition of the substandard understanding and management of the mental health problems of Australians.

Such a forward-thinking view, and commitment to long-term investment, is also necessary for musculoskeletal pain. There are arguments for better alignment of research funding distribution, disease burden, and integration of rigorous evaluation into service delivery to help identify and minimise inefficiencies in this area.

Musculoskeletal pain has a greater impact on the function of Australians than any other health condition and its cost makes a measurable dent in the GDP. Yet funding for research and efforts to improve service delivery are not forthcoming.

Given the evidence linking musculoskeletal pain to early retirement, and identified inefficiencies in care delivery, it is likely significant investment in the area will provide a measurable return. Musculoskeletal conditions also have no voice at present in the debate around preventive public health initiatives despite the demonstrable individual and societal burden, and established links to generic health risk factors, including obesity, smoking and poor mental health.

It might not kill us, but it is making us suffer.

Dr Steve Kamper has a background in physiotherapy, he is Senior Research Fellow at the George Institute, funded by a fellowship from the NHMRC. His interests include musculoskeletal pain in adolescents, patient expectations and research methods.

2 thoughts on “Musculoskeletal pain on the back burner

  1. scott masters says:

    Great article Steve – it would seem a first step is increased training in health graduates across all disciplines – the current medical courses in Australia for instance would be lucky to get 5% of the course devoted to musculoskeletal medicine (MSM). Similarly GP training is very hit and miss around MSM.

  2. Steve Kamper says:

    I suspect you are right Scott. I have heard similar reports about the volume of pain education generally and MSK pain content specifically in pre-license medical training. I think the issue will need a coordinated approach though, involving a good look at which professionals are getting what training, what is happening in the public health space, clinical health service delivery, and the funding of research.

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