Diffusing the time bomb

Joint pain and stiffness are increasingly affecting more people at a younger age, and the number of sufferers is set to soar, as Ellie Broughton discovers

There are two factors that most rheumatologists blame for the wave of musculoskeletal disease we face: the ageing UK population and our obesity problem. We can’t do much to hold back the hands of time, admittedly, but losing weight is the fastest way to take a load off your joints.

Some 20 per cent more adults are obese today compared with Britain in the Sixties and a survey by the Department of Health in 2010 discovered that just 57 per cent of people who were overweight had tried to shed the extra pounds in the past year.

The British way of life has become much more sedentary since our parents’ generations. Eight in ten adults in the Sixties used to have a 30-minute walk every day – now the figure is just half that. The average woman’s waist is six inches bigger than her 1950s counterpart and we do around half the amount of high-energy chores around the house compared with the Sixties.

Surgeons in the UK have reported that the average age of patients having knee operations is getting younger. The reason? Obesity.

Of course, our understanding of musculoskeletal disease is better than it was a few years ago; for example, the pain disorder fibromyalgia wasn’t officially recognised until 1990. But the prevalence of common musculoskeletal diseases and the rate of new diagnoses will force British society to adapt fast.

Few have begun to really question what a longer working life will be like for, say, a bricklayer with sore joints or a bike courier with a hip replacement.

There are 70,000 knee replacements a year in the UK and the number is rising

Over the last 70 years, Britain has taken a massive stride forward in terms of some musculoskeletal problems. Rickets, for instance, has now almost disappeared, as we realised the importance of a calcium-rich diet and later the role of vitamin D in absorbing it. Childhood diseases which warp the skeleton – namely polio and tuberculosis – have also been largely eliminated through immunisation.

Despite being something of a political football, Britain’s school milk programme has helped improve the calcium intake, and thus the bone health, of the country’s poorest children. Altogether, NHS public health campaigns have saved many children from growing up with bone and joint problems.

A 2011 report by the University of Manchester’s School of Medicine, A Heavy Burden, reported the number of people with rheumatoid arthritis is thought to be in decline, as is the severity of new diagnoses.

However, the same research reported that the incidence of gout was consistently high in men and increased with age – bad news for the ageing population.

Osteoporosis, the most common form of musculoskeletal disease in the UK, became more common during the Eighties, according to the report, and referrals for elective hand surgery trebled during the next decade. Back pain reportedly doubled between 1956 and 1995.

Despite developments in bone and joint health, no cure has yet been discovered for arthritis or osteoporosis, probably because these diseases are associated with ageing, although drugs can reduce the symptoms.

For those suffering from painful musculoskeletal conditions, pain relief has improved over the last 70 years; aspirin, paracetamol and ibuprofen have become affordable for most as drug patents have expired, and the NHS began to prescribe the painkillers freely.

The development of bisphosphonates in the 1960s created a new option for patients with osteoporosis and, since the late-Nineties, drugs called tumour necrosis factor (TNF) inhibitors have helped slow auto-immune diseases, including rheumatoid arthritis and ankylosing spondylitis.

Judith Brodie, chief executive of Arthritis Care, says that there is hope, but points out that there is still a key challenge in our way. “There is, over generations, increasing knowledge and awareness of how best to treat different forms of arthritis and what makes a difference. For instance, prescribing TNF inhibitors for rheumatoid arthritis can be transformative. But, while there have been new treatments for pain, that is still a real challenge,” she says.

Managing the chronic pain that comes with bone and joint disease is still a complicated business. The invention of transcutaneous electronic nerve stimulation (TENS) machines in the mid-1970s was a breakthrough for some patients.

But Arthritis Care’s 2012 report OA Nation found that access to treatment was limited for many patients. A third of people with osteoarthritis never see their doctor. For those who do, diagnosis is reported to be slow; more than a third said it took between three and eleven appointments for a doctor to diagnose the condition.

The cost of caring for Britain’s bones will boom over the next 20 years. Cost of treating and caring for hip fractures in the UK could top £6 billion by 2036, according to Age UK. Falls and fractures will increase emergency admissions, one of the biggest areas of NHS spending already. But bone and joint conditions are also due to take a bigger chunk of prescribing budgets.

Patients incorrectly mixing NSAIDs (non-steroidal anti-inflammatory drugs), such as aspirin and ibuprofen, with other drugs is also responsible for many emergency admissions to hospital, the majority of which are for elderly people with, in some cases, numerous other illnesses.

Pain, lack of mobility and flexibility also affect the British economy when employees’ poor bone and joint health forces them to take time off or even quit work. The Health and Safety Executive’s 2010 report on ageing and musculoskeletal disorders found that, despite workplaces valuing their more senior employees, little is being done to keep these people at work. It concludes: “An older workforce has implications [which] include providing additional support for worker requirements, changing the workplace attitudes towards ageing, providing a positive knowledge base, adjusting the workplace design and accommodations, and improving worker-employer relationships [co-operation].”

The implication was that, even two years ago, most UK employers were not even at the first stage of this enormous, but necessary, change.

Surgeons report that patients for knee operations are getting younger and some have called for better testing of implants. Fifty-somethings receiving new knees and hips have a much more active lifestyle than the average implant candidate ten years ago, and are likely to be using them for longer as the average lifespan extends. There are 70,000 knee replacements a year in the UK and the number is rising.

The growing number of people with musculoskeletal disease will also have a somewhat more sobering psychological impact on patients. Medicine is already failing to deal with the impact of chronic pain on patients like Nan Maitland, who cited arthritic pain as the reason for her assisted suicide in Switzerland in 2011.

While the disease is not a terminal diagnosis, Arthritis Research UK says that seven in ten patients feel depressed when the pain of the disease is at its worst. Musculoskeletal disease is typically characterised by pain and, as patients find themselves less able to work, socialise and pursue their interests, conditions start to impact on mental health and wellbeing.

As the NHS adapts to its new clinically-led structure, clinical commissioning groups (CCGs) – the groups of GPs who will be in charge of NHS budgets – will have the chance to make new investments in musculoskeletal disease care.

However, the so-called “Nicholson challenge” of making efficiency savings of £15 billion to £20 billion between 2011 and 2014, will force these GP-led groups to make significant cutbacks.

Hospital admissions and referrals have already been heavily restricted; knee surgery or replacement and hip operations have been rationed by some primary care trusts and CCGs. Prescribing budgets have been slashed, and many GPs have chosen to focus on other common long-term conditions, such as diabetes and chronic obstructive pulmonary disease, rather than musculoskeletal problems.

Self-care and self-management are buzz words cited by health economists as a quick route to cost savings; it is likely that some patients suffering from pain will be encouraged to try to manage their symptoms themselves using painkillers, exercise programmes and self-massage. While this prescription will no doubt alleviate some symptoms, a number of patients will ultimately feel they have been left to deal with their conditions themselves.

Whether self-care is an appropriate suggestion for patients suffering from musculoskeletal problems is a difficult question. What is not debatable is that these diseases will force huge changes to the way we work and the way we manage NHS resources for the foreseeable future.