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Rheumatology services to meet the needs of people with musculoskeletal conditions
Musculoskeletal conditions are very common across Europe, affecting all ages, and the associated physical disability is an enormous burden on individuals and society.1 They can be effectively prevented and controlled in many situations but this is not at present fully achieved, partly because people—both the public and health professionals—are unaware of what modern management has to offer. Timely access to appropriate management is essential for all those who have musculoskeletal problems if the burden is to be reduced,2 but this is not the situation for all across Europe. The European Union of Medical Specialists (UEMS) Section of Rheumatology/European Board of Rheumatology have made recommendations in this issue of what services are required to meet these needs.
There are several reasons why the best outcomes are not achieved for people with musculoskeletal conditions. There is a lack of understanding of the impact that these conditions have, as they are mostly non-fatal and the greatest effects are at increasing ages. Although the impact of rheumatoid arthritis is better recognised, many consider conditions such as osteoarthritis and osteoporosis as natural parts of ageing, and back pain is so common that it is often considered normal in people performing heavy-lifting jobs. As a consequence, people with musculoskeletal pain often delay seeing a physician and do not always follow advice as they fear that the treatment is worse than their problem.3 When they do consult a primary care physician, the physician may not be expert or interested in the management of the musculoskeletal problem. Undergraduate medical education is inadequate in musculoskeletal conditions,4,5 and many primary care physicians do not gain any further specific training in the management of these conditions. Many doctors will, therefore, have little or an outdated understanding of what can be achieved with modern treatment. For example, they may not be able to recognise the early clinical features of rheumatoid arthritis or be aware of the need for early expert treatment to avoid long-term disability. People with a musculoskeletal problem may be referred to a specialist but there is a spectrum to choose from, such as rheumatologists, orthopaedic surgeons, physical medicine and rehabilitationalists, anaesthetists working in pain clinics, sports physicians or other health professionals such as physiotherapists, chiropractors or osteopaths. Although all should have a similar expertise in assessment and the general aspects of management of musculoskeletal problems, and differ mainly by the types of interventions they use, this is often not the case. Training lacks coordination between the disciplines, so there is little commonality of general approach to the patients and their problem. It is, however, recognised that an integrated approach with all the disciplines and professionals working together in a seamless way is the way of achieving the best outcome for the patient.6,7 How can the situation be improved?
As a first step, there needs to be a greater awareness of the importance of musculoskeletal health at the political level. Priority needs to be given to the development and implementation of policies at a national or regional level to promote and maintain musculoskeletal health, for case finding and management of those at high risk or with early features of musculoskeletal conditions, and also to ensure that health systems provide timely access to care with availability of treatments where indicated.2 The public health arguments for this priority are strong, with an enormous burden on individuals in terms of impaired quality of life and disability, and on society in terms of costs of health and social care. In Europe, 20–30% of adults are affected at any one time by musculoskeletal pain and these conditions are among the top 10 causes of disability. In the World Health Organization (WHO) Global Burden of Disease Study,8 osteoarthritis in high-income countries ranked 5th as a cause of years lived with disability and 10th as a cause of disability-adjusted life years (a measurement that includes premature mortality). One in five of all Europeans receiving long-term treatment is for rheumatism and arthritis.9 These conditions represent almost 25% of the total cost of illness in European countries.10 With the increasing number of older people and the changes in lifestyle occurring throughout Europe, the burden is predicted to increase dramatically unless action is taken now. This has been recognised by the United Nations and WHO with the endorsement of the Bone and Joint Decade.11 There is also growing concern of the growing burden of all non-communicable diseases in Western countries,12–14 and all governments across Europe have agreed on the need for urgent action.15 There is much awareness of what can be done to prevent cardiovascular disease, cancer and diabetes by lifestyle modification as well as pharmaceutical interventions, but there is a lack of awareness of what can be achieved for musculoskeletal conditions by lifestyle interventions, pharmaceutical treatments, surgery and rehabilitation. There is a lack of knowledge about the benefits of weight reduction and physical activity on osteoarthritis,13 the overall advantages of pain management for many versus potential side effects3 and the current prognosis for someone with recently diagnosed rheumatoid arthritis. The importance of early appropriate treatment for many musculoskeletal conditions to prevent chronification and to reduce disability is undervalued. Evidence-based strategies for the prevention and management of the spectrum of musculoskeletal conditions have been produced2 to try to close this information gap and create a more positive environment, and there are an increasing number of European League against Rheumatism Guidelines and Cochrane reviews to underpin such strategies.
Health systems have to be able to deal with the increase in musculoskeletal and other non-communicable conditions. Although there is a focus on primary prevention by dealing with risk factors such as obesity, physical inactivity, alcohol and smoking,15 there is also a need to ensure that people at risk can be identified and that those with musculoskeletal problems have timely access to appropriate care. The WHO European Strategy for prevention and control of non-communicable diseases, endorsed by all European governments, recognises the importance of musculoskeletal conditions and emphasises that health and medical services should be fit for purpose, responding to present disease burden, and that there needs to be universal access to health promotion, disease prevention and health services.15 This needs physical and financial resources as well as appropriate competencies among the healthcare providers.
The health services needed by people with musculoskeletal conditions should provide integrated coordinated multidisciplinary, multiprofessional care focused seamlessly around the needs of the individual—dealing with their condition, its effect upon them, as well as enabling them to gain the skills necessary to take responsibility for their own musculoskeletal condition in the long term and make informed choices so that they can participate actively in their own management.2,16 The aspirations of those with musculoskeletal conditions17 must also be considered. For many people with musculoskeletal conditions, this can be provided in the community and in primary care, but many will also need the diagnostic and management expertise of a specialist team in secondary care supported by appropriate facilities and services. Most importantly, people should be assessed and managed by someone with the competency appropriate to their problem. The lack of specific education and training by undergraduates and by most in primary care means that many musculoskeletal conditions will benefit from specialist involvement in their management.
A rheumatology service is key to the provision of these health services, working closely with primary care and within an integrated coordinated multidisciplinary, multiprofessional team with close working relationships with other relevant specialities and professions. Rheumatologists are trained in the medical management of the spectrum of musculoskeletal conditions18 and deal with a variety of problems which, in general, fall into three categories: (1) patients with short-term problems that benefit from specific therapy or procedures, such as regional pain syndromes; (2) patients requiring diagnosis, assessment, advice or counselling usually for chronic disorders, such as osteoarthritis, gout, fibromyalgia and back pain, which, with appropriate advice to the primary care physician, can be managed in the community; and (3) patients with potentially progressive musculoskeletal conditions, such as inflammatory joint disease, autoimmune disorders and other chronic progressive diseases that require close supervision to ensure the best outcome of treatment. Some rheumatologists are more focused on particular musculoskeletal conditions, such as inflammatory joint disease or connective tissue diseases. Some are closely linked with internal medicine and others with physical medicine/rehabilitation. This varies both within and between countries. Rheumatologists will, however, work with others who may manage different aspects of musculoskeletal conditions to ensure that there are appropriate services for all people with any such problem.
What do rheumatologists need to be able to provide such a service? They need the appropriate competencies through training18 in centres that offer the necessary broad experience,19 and they also require the appropriate resources to offer clinical services that cater to the varying needs of the different musculoskeletal conditions. The recommendations of the UEMS/European Board for Rheumatology in this issue16 consider what a rheumatology service should be able to offer to meet these needs and the resources that such a service is likely to require in terms of expertise and facilities. Timely access to care at the appropriate level of expertise are the key issues. The need for a multidisciplinary team, modern diagnostics and strong working relationships with key disciplines is emphasised. The changes in outcome that have reduced the need of inpatient facilities have not totally taken away this need. However, it is important that what can be achieved by such a multidisciplinary and multiprofessional rheumatology service is clearly defined. Care pathways are being developed in the UK to establish what aspects of a musculoskeletal problem can be dealt with in what health setting,7 and it is important to be able to justify why certain aspects should be undertaken by, or under the supervision of, rheumatologists in terms of meeting the needs of the patient and meeting quality standards. We cannot ignore the need to consider cost effectiveness, as this is of prime importance to most funders of health care. The aim is that the UEMS/European Board of Rheumatology recommendations in this issue will help rheumatologists build a case for developing and providing rheumatology services that meet the needs of people with musculoskeletal conditions in 2007.
Rheumatology services to meet the needs of people with musculoskeletal conditions
Competing interests: None declared.
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