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Editorial
Prevention of Rheumatic Disease
RICHARD D. WIGLEY, MB, ChB, FRCP(London),
New Zealand. Address reprint requests to Dr. Wigley. E-mail: r.d.Wigley@xtra.co.nz Since editing a monograph on the primary prevention of rheumatic disease in 19941 much new information has accumulated. Except for back pain, which is the commonest pain of all, there has been little concerted effort to apply the lessons learned. The European Action Towards Musculoskeletal Health proposes a public health strategy to reduce the vast public burden of musculoskeletal (MSK) conditions. In response to this, Woolf and Akesson2 have assembled a review of the possibilities for primary prevention and control (secondary prevention) of the MSK disorders, including arthritis. They emphasize the formidable size of the problem: Up to 30% of adults are affected at any one time in the UK. The COPCORD studies3 show that this is a major problem in more than 12 developing countries, although predictably less than in developed nations, where populations are older. This has highlighted the need for internationally agreed on diagnostic criteria4. Agreement is difficult, as the various conditions often overlap and more than one condition often coexist in the same patient5. Rheumatologists who deal mainly with rheumatoid arthritis (RA) tend to be pessimistic about primary prevention, as controllable causes of RA, and the other inflammatory arthritides, remain elusive. They do have increasing success in secondary prevention using the biological agents. Osteoarthritis (OA) is the most common form of arthritis. Evidence accumulates that this is not simply an inevitable result of aging but is of multifactorial causation. Hunter, et al6 list occupation, physical activity, quadriceps strength, joint injury, obesity, diet, hormones, and bone density as modifiable factors for knee OA. There is a high risk of OA in those doing heavy work7. We have known since the classic epidemiological studies of Lawrence and Kellgren8 that miners are at high risk of lumbar disc disease and what has been called degenerative disease of the spine. The word "degenerative" is in fact misleading as it implies inevitable deterioration due to age, thereby diverting attention from the other risk factors. The same word appeals to insurers, who interpret it to mean age causation so they can deny coverage. Employers often deny responsibility for MSK disorders in employees although, paradoxically, they would gain from prevention by retaining the skills of experienced staff and would save the costs of retraining new staff. Basic research9 has suggested a physical mechanism for the failure of cartilage. The elastic decorans bonds maintain the structural shape modules and elasticity of cartilage. If these are stretched to breaking point, the cartilage fails, with subsequent enzymatic breakdown. This supports the other evidence that avoidance of persistent overload and accidents will reduce the prevalence of OA, which otherwise will rise with the increasing average age at death in developed nations. Attempts to control cartilage breakdown or to promote cartilage healing with glucosamine have not yet proved to be effective. As in RA, joint replacement has been a great advance in minimizing impairment from end stage hip and knee arthritis. MSK disorders are commonly work related and caused by the occupation. The US National Institute for Occupational Safety and Health (NIOSH) review10 of workplace factors focuses on repetition, force, posture, and vibration. This remains a standard reference despite being published more than a decade ago. The US National Research Council11 has taken this further, drawing on a wide spectrum of expertise. Specialists in occupational medicine are in a key position to intervene but many may be too close to insurers and employers to be impartial. Unfortunately legal disputes over compensation insurance have led to polarization of views from those who question causal associations12 to those who accept work causation. This has delayed or prevented prevention. Back pain education aimed at prevention has been shown to be effective and feasible13. Upper limb pain is common in industry. A two year prospective study of 1513 subjects14 showed that highly repetitive work predicted arm pain; heavy lifting and prolonged standing predicted low back pain; and heavy pushing or pulling predicted lower limb pain. These all present opportunities for prevention and control. Clearly there is ample scope for ergonomic intervention in work-related upper limb pain15. Chronic neuropathic pain syndromes are often said to be idiopathic (of unknown cause). This word should be used with caution as evidence accrues that such pain syndromes are multifactorial in origin. They can be induced by sustained nociceptive input from injuries, physical disease, and psychosocial factors, which can also derive from work stresses16. These factors are susceptible to prevention14. Gender and genetic predisposition are not. Fibromyalgia, often said to be idiopathic, is increasingly regarded as the end of a spectrum of pain disorders rather than as a discrete disease17. Much progress has been made in the prevention and control of osteoporosis. This ranges from physical fitness to calcium, vitamin D and bisphosphonate medication, and the avoidance of falls and so fractures18. Osteoporosis increases the risk of falls in the elderly that are common causes of low force fractures, joint damage, and mortality. Precise measures of bone density are now widely available in developed countries. In developing countries only calcium and vitamin D are available for prevention although these populations are usually more physically active. The MSK complications of infectious diseases such as sexually transmitted diseases, AIDS, and tropical disease, detailed in the monograph1, are dealt with by infectious and tropical disease specialists. Rheumatic fever and rheumatic heart disease are now well controlled in the West but remain a major challenge in indigenous populations such as Australian aborigines19. Gout prevention is also possible. Severe endemic gout in Sulawesi, Indonesia, was shown to be due to a locally made liquor. A successful control program has been initiated involving education of the local general practitioners20. Allopurinol has provided effective control of gout. Gout induced by thiazide diuretics is preventable. Health administrations focus on lethal diseases at the expense of chronic disabling MSK disorders although these are so prevalent and cause so much longterm pain and suffering with very high direct and indirect costs21. Most musculoskeletal disorders do not contribute to hospital costs, except for joint replacements and the connective tissue disorders, which are much less common and are not preventable except for drug induced lupus. Prevention of obesity, alcohol and smoking, and infectious diseases is covered by existing public health programs as they increase the risk of many lethal diseases. Education of both the public and the medical profession will be necessary for an effective program22. This will take time and patience. Lawrence8 detailed the risk of musculoskeletal disorders in a number of industries half a century ago. It took as long for the UK Royal Navy to apply Dr. Lind's discovery that citrus fruit prevented scurvy, so don't despair. 2. Woolf AD, Akesson K. Can we reduce the burden of musculoskeletal conditions? The European action towards better musculoskeletal health. Best Pract Res Clin Rheumatol 2007; 21:1-3. [MEDLINE] 3. Chopra A. COPCORD-An unrecognized fountainhead of community rheumatology in developing countries. J Rheumatol 2004;31:2320-2. [MEDLINE] 4. Walker-Bone K, Cooper C. Hard work never hurt anyone — or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb. Ann Rheum Dis. 2005;64:1112-7. [MEDLINE] 5. Helliwell PS, Bennett RM, Littlejohn G, Muirden KD, Wigley RD. Towards epidemiological criteria for soft tissue disorders of the arm. Occupat Med 2003:53:313-9. [MEDLINE] 6. Hunter DJ, March L, Sambrook PN. Knee osteoarthritis: the influence of environmental factors. Clin Exper Rheumatol 2002;20:93-100. [MEDLINE] 7. Rossignol M, Leclerc A, Alleart FA, et al. Primary osteoarthritis of hip, knee, and hand in relation to occupational exposure. Occup Environ Med 2005;62::772-7. [MEDLINE] 8. Lawrence JS. Rheumatism in populations. London: William Heineman; 1977: Ch 14. 9. Scott J, Wigley RD. Cartilage is held together by elastic carbohydrate strings. J Rheumatol 2007;34:8-9: [MEDLINE] 10. Bernard, BP. Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Cincinnati; NIOSH Publication 97-141; 1997. 11. Musculoskeletal diseases and the workplace. Low back and upper extremities. Washington: National Academy Press; 2001. 12. Hadler N. If you have to prove that you are ill, you can't get better. Spine 1996;2:2397-400. [MEDLINE] 13. Buchbinder R, Jolley D. Improvements in general practitioner beliefs and stated management of back pain persist 4.5 years after the cessation of a public health media campaign. Spine 2007;32:E156-62. [MEDLINE] 14. Andersen JH, Haahr JP, Frost P. Risk factors for more severe regional musculoskeletal symptoms. A two-year prospective study of a general working population. Arthritis Rheum 2007;56:1355-64. [MEDLINE] 15. Rempel D, Barr A, Brafman D, Young E. The effect of six keyboard designs on wrist and forearm postures. Applied ergonomics 2007;38:293-8. [MEDLINE] 16. Macfarlane G. Hunt IM, Silman AJ. Role of mechanical and psychosocial factors in the onset of forearm pain; prospective population study. BMJ 2000;321:676-9. [MEDLINE] 17. Wolfe F. The fibromyalgia problem. J Rheumatol 1997;24: 1247-9. [MEDLINE] 18. Sambrook PH, Cameron ID, Chen DS, et al. Influence of fall related factors and bone strength on fracture risk in the frail elderly. Osteoporosis Int 2007;18:603-10. [MEDLINE] 19. McDonald MI, Towers RJ, Andrews RM, Benger N, Currie BJ, Carapetis JR. Low rates of streptococcal pharyngitis and high rates of pyoderma in Australian aboriginal communities where acute rheumatic fever is hyperendemic. Clin Infect Dis 2006;43:683-9. [MEDLINE] 20. Padang C, Muirden KD, Schumacher R, Darmawan J. Characteristics of chronic gout in northern Sulawesi, Indonesia. J Rheumatol 2006;33:1813-7. [MEDLINE] 21. Bergman S. Public health perspective – how to improve the Musculo-skeletal health of the population. Best Pract Res Clin Rheumatol 2007;21:191-204. [MEDLINE] 22. Woolf AD, Akesson K. Education in musculoskeletal health — How can it be improved to meet growing needs. J Rheumatol 2007;34:455-7. [MEDLINE]
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