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Clinical and epidemiological research
Extended report
Burden of musculoskeletal disorders in the Eastern Mediterranean Region, 1990–2013: findings from the Global Burden of Disease Study 2013
  1. Maziar Moradi-Lakeh1,2,
  2. Mohammad H Forouzanfar1,
  3. Stein Emil Vollset1,3,4,
  4. Charbel El Bcheraoui1,
  5. Farah Daoud1,
  6. Ashkan Afshin1,
  7. Raghid Charara1,
  8. Ibrahim Khalil1,
  9. Hideki Higashi5,
  10. Mohamed Magdy Abd El Razek6,
  11. Aliasghar Ahmad Kiadaliri7,
  12. Khurshid Alam8,9,10,
  13. Nadia Akseer11,12,
  14. Nawal Al-Hamad13,
  15. Raghib Ali14,
  16. Mohammad AbdulAziz AlMazroa15,
  17. Mahmoud A Alomari16,
  18. Abdullah A Al-Rabeeah15,
  19. Ubai Alsharif17,
  20. Khalid A Altirkawi18,
  21. Suleman Atique19,
  22. Alaa Badawi20,
  23. Lope H Barrero21,
  24. Mohammed Basulaiman15,
  25. Shahrzad Bazargan-Hejazi22,23,
  26. Neeraj Bedi24,
  27. Isabela M Bensenor25,
  28. Rachelle Buchbinder26,27,
  29. Hadi Danawi28,
  30. Samath D Dharmaratne29,
  31. Faiez Zannad30,
  32. Maryam S Farvid31,32,
  33. Seyed-Mohammad Fereshtehnejad33,
  34. Farshad Farzadfar34,
  35. Florian Fischer35,
  36. Rahul Gupta36,
  37. Randah Ribhi Hamadeh37,
  38. Samer Hamidi38,
  39. Masako Horino39,40,
  40. Damian G Hoy41,
  41. Mohamed Hsairi42,
  42. Abdullatif Husseini43,
  43. Mehdi Javanbakht44,
  44. Jost B Jonas45,
  45. Amir Kasaeian46,47,
  46. Ejaz Ahmad Khan48,
  47. Jagdish Khubchandani49,
  48. Ann Kristin Knudsen50,
  49. Jacek A Kopec51,
  50. Raimundas Lunevicius52,53,
  51. Hassan Magdy Abd El Razek54,
  52. Azeem Majeed55,
  53. Reza Malekzadeh56,
  54. Kedar Mate57,
  55. Alem Mehari58,
  56. Michele Meltzer59,
  57. Ziad A Memish15,60,
  58. Mojde Mirarefin61,
  59. Shafiu Mohammed62,63,
  60. Aliya Naheed64,
  61. Carla Makhlouf Obermeyer65,
  62. In-Hwan Oh66,
  63. Eun-Kee Park67,
  64. Emmanuel Kwame Peprah68,
  65. Farshad Pourmalek51,
  66. Mostafa Qorbani69,
  67. Anwar Rafay70,71,
  68. Vafa Rahimi-Movaghar72,
  69. Rahman Shiri73,
  70. Sajjad Ur Rahman74,
  71. Rajesh Kumar Rai75,
  72. Saleem M Rana70,71,
  73. Sadaf G Sepanlou76,
  74. Masood Ali Shaikh77,
  75. Ivy Shiue78,79,
  76. Abla Mehio Sibai80,
  77. Diego Augusto Santos Silva81,
  78. Jasvinder A Singh82,
  79. Jens Christoffer Skogen3,83,
  80. Abdullah Sulieman Terkawi84,85,86,
  81. Kingsley N Ukwaja87,
  82. Ronny Westerman88,89,
  83. Naohiro Yonemoto90,
  84. Seok-Jun Yoon91,
  85. Mustafa Z Younis92,
  86. Zoubida Zaidi93,
  87. Maysaa El Sayed Zaki54,
  88. Stephen S Lim1,
  89. Haidong Wang1,
  90. Theo Vos1,
  91. Mohsen Naghavi1,
  92. Alan D Lopez1,94,
  93. Christopher J L Murray1,
  94. Ali H Mokdad1
  1. 1 Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
  2. 2 Department of Community Medicine, Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
  3. 3 Norwegian Institute of Public Health, Bergen, Norway
  4. 4 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
  5. 5 Japan International Cooperation Agency, Lusaka, Zambia
  6. 6 Ophthalmology resident in Aswan University Hospital, Aswan, Egypt
  7. 7 Clinical Epidemiology Unit, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
  8. 8 Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
  9. 9 The University of Melbourne, Melbourne, Victoria, Australia
  10. 10 The University of Sydney, Sydney, New South Wales, Australia
  11. 11 Hospital for Sick Children, Toronto, Ontario, Canada
  12. 12 University of Toronto, Toronto, Ontario, Canada
  13. 13 Food and Nutrition Administration, Ministry of Health, Safat, Kuwait
  14. 14 University of Oxford, Oxford, UK
  15. 15 Saudi Ministry of Health, Riyadh, Saudi Arabia
  16. 16 Division of Physical Therapy, Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
  17. 17 Charité Universitätsmedizin, Berlin, Germany
  18. 18 King Saud University, Riyadh, Saudi Arabia
  19. 19 Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
  20. 20 Public Health Agency of Canada, Toronto, Ontario, Canada
  21. 21 Department of Industrial Engineering, School of Engineering, Pontificia Universidad Javeriana, Bogota, Colombia
  22. 22 Charles R. Drew University of Medicine and Science, Los Angeles, California, USA
  23. 23 David Geffen School of Medicine, University of California at Los Angeles (UCLA), California, USA
  24. 24 College of Public Health and Tropical Medicine, Jazan, Saudi Arabia
  25. 25 University of São Paulo, São Paulo, Brazil
  26. 26 Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
  27. 27 Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  28. 28 Walden University, Minneapolis, Minnesota, USA
  29. 29 Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
  30. 30 Clinical Investigation Centre INSERM (the National Institute for Health and Medical Research), Université de Lorraine, Vandoeuvre les Nancy, France
  31. 31 Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  32. 32 Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts, USA
  33. 33 Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institute, Stockholm, Sweden
  34. 34 Non-Communicable Diseases Research Center, Endocrine and Metabolic Research Institute, Tehran University of Medical Sciences, Tehran, Iran
  35. 35 Bielefeld University, Bielefeld, Germany
  36. 36 West Virginia Bureau for Public Health, Charleston, West Virginia, USA
  37. 37 Arabian Gulf University, Manama, Bahrain
  38. 38 Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates
  39. 39 Nevada Division of Behavior and Public Health, Carson City, Nevada, USA
  40. 40 Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
  41. 41 Public Health Division, Secretariat of the Pacific Community, Noumea, New Caledonia
  42. 42 Salah Azaiz Institute, Tunis, Tunisia
  43. 43 Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
  44. 44 Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
  45. 45 Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
  46. 46 Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
  47. 47 Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
  48. 48 Health Services Academy, Islamabad, Pakistan
  49. 49 Ball State University, Muncie, Indiana, USA
  50. 50 Department of Health Registries, Norwegian Institute of Public Health, Bergen, Norway
  51. 51 University of British Columbia, Vancouver, British Columbia, Canada
  52. 52 Aintree University Hospital National Health Service Foundation Trust, Liverpool, UK
  53. 53 School of Medicine, University of Liverpool, Liverpool, UK
  54. 54 Mansoura Faculty of Medicine, Mansoura, Egypt
  55. 55 Imperial College London, London, UK
  56. 56 Digestive Disease Research Institute, Tehran Universities of Medical Sciences, Tehran, Iran
  57. 57 McGill University, Montreal, Quebec, Canada
  58. 58 College of Medicine, Howard University, Washington DC, USA
  59. 59 Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  60. 60 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
  61. 61 Hunger Action Los Angeles, Los Angeles, California, USA
  62. 62 Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria
  63. 63 Institute of Public Health, Heidelberg University, Heidelberg, Germany
  64. 64 International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
  65. 65 Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
  66. 66 Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, South Korea
  67. 67 Department of Medical Humanities and Social Medicine, College of Medicine, Kosin University, Busan, South Korea
  68. 68 National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
  69. 69 Noncommunicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
  70. 70 Contech International Health Consultants, Lahore, Pakistan
  71. 71 Contech School of Public Health, Lahore, Pakistan
  72. 72 Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
  73. 73 Finnish Institute of Occupational Health, Helsinki, Finland
  74. 74 Sweidi Hospital, Riyadh, Saudi Arabia
  75. 75 Society for Health and Demographic Surveillance, Suri, India
  76. 76 Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
  77. 77 Independent Consultant, Karachi, Pakistan
  78. 78 Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
  79. 79 Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK
  80. 80 Department of Epidemiology & Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
  81. 81 Federal University of Santa Catarina, Florianópolis, Brazil
  82. 82 University of Alabama at Birmingham, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
  83. 83 Alcohol and Drug Research Western Norway, Stavanger University Hospital, Stavanger, Norway
  84. 84 Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
  85. 85 Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, USA
  86. 86 Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia
  87. 87 Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
  88. 88 Federal Institute for Population Research, Wiesbaden, Germany
  89. 89 German National Cohort Consortium, Heidelberg, Germany
  90. 90 Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan
  91. 91 Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
  92. 92 Jackson State University, Jackson, Mississippi, USA
  93. 93 University Hospital, Setif, Algeria
  94. 94 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Professor Ali Mokdad, Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USA; mokdaa{at}uw.edu

Abstract

Objectives We used findings from the Global Burden of Disease Study 2013 to report the burden of musculoskeletal disorders in the Eastern Mediterranean Region (EMR).

Methods The burden of musculoskeletal disorders was calculated for the EMR's 22 countries between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, death, years of live lost, years lived with disability and disability-adjusted life years (DALYs).

Results For musculoskeletal disorders, the crude DALYs rate per 100 000 increased from 1297.1 (95% uncertainty interval (UI) 924.3–1703.4) in 1990 to 1606.0 (95% UI 1141.2–2130.4) in 2013. During 1990–2013, the total DALYs of musculoskeletal disorders increased by 105.2% in the EMR compared with a 58.0% increase in the rest of the world. The burden of musculoskeletal disorders as a proportion of total DALYs increased from 2.4% (95% UI 1.7–3.0) in 1990 to 4.7% (95% UI 3.6–5.8) in 2013. The range of point prevalence (per 1000) among the EMR countries was 28.2–136.0 for low back pain, 27.3–49.7 for neck pain, 9.7–37.3 for osteoarthritis (OA), 0.6–2.2 for rheumatoid arthritis and 0.1–0.8 for gout. Low back pain and neck pain had the highest burden in EMR countries.

Conclusions This study shows a high burden of musculoskeletal disorders, with a faster increase in EMR compared with the rest of the world. The reasons for this faster increase need to be explored. Our findings call for incorporating prevention and control programmes that should include improving health data, addressing risk factors, providing evidence-based care and community programmes to increase awareness.

  • Epidemiology
  • Low Back Pain
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Gout

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/annrheumdis-2016-210146

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    Introduction

    Musculoskeletal disorders have been underestimated and even ignored for a long time, mainly due to their low fatality rate and being viewed as irreversible conditions or simply part of the ageing process.1 The considerable contribution of musculoskeletal disorders is now more clear and several studies have quantified the significant burden of musculoskeletal disorders.2 They are among the most prevalent causes of absence from work and medical visits worldwide.2 High frequency, chronicity and resultant disability of musculoskeletal disorders impose a considerable economic burden on the communities. Population ageing is expected to dramatically increase the burden of musculoskeletal conditions over the coming decades.3 Despite these facts, musculoskeletal disorders have not been a focus of public health programmes, especially in low-income and middle-income countries.4

    In the Eastern Mediterranean Region (EMR), epidemiological data on musculoskeletal disorders are sparse and not easily comparable. Most of the data in this region come from baseline surveys of the Community Oriented Program for Control of Rheumatic Diseases (COPCORD). The programme, designed by the WHO and the International League of Associations for Rheumatology in the 1980s, is presumably the most eminent public health programme to tackle the burden of musculoskeletal disorders in low/middle-income countries.5 Some countries in the EMR including Egypt, Iran, Kuwait, Lebanon, Pakistan and Tunisia have launched COPCORD projects in the past two decades.6 The COPCORD baseline surveys have shown a high prevalence of musculoskeletal conditions in the region; for instance, musculoskeletal complaints during the past seven days were reported by around 45% of people in Iran, based on four samples in rural and urban areas. The most common anatomical sites of symptoms were knees (27%), dorsolumbar spine (24%), shoulders (16%) and cervical spine (14%).7 Lifetime prevalence of musculoskeletal problems was reported by around 33% of people in Lebanon, with a current point prevalence of approximately 24%.8 About 27% of individuals in Kuwait reported musculoskeletal pain, and the most common sites of pain were knees, back and shoulders.9 In the northern part of Pakistan in 1997, 14.8% of people had rheumatic diseases with higher prevalence in rural areas (16.5%) compared with poor urban (13.6%) and affluent urban areas (10.7%).10 Musculoskeletal conditions (complaints or disorders) were generally more common in females compared with males.8–12 The overall prevalence of musculoskeletal conditions was higher in rural areas compared with urban.10 ,13 Original data from other countries of the region are usually limited to specific diseases.14–17 In the demographic and health survey of Palestine, 2% of the population reported a diagnosis of musculoskeletal diseases, with an increasing prevalence with age.18 Some of the countries in the region have no accessible original data on the magnitude and intensity of musculoskeletal disorders.

    There is not a comprehensive summary or comparable data on the burden of musculoskeletal disorders in the countries of this region. In this report, which is part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013), we present the prevalence and burden of musculoskeletal disorders (low back pain, neck pain, osteoarthritis, rheumatoid arthritis, gout and other musculoskeletal disorders) at the regional and national levels in the EMR from 1990 to 2013, as well as the attributable burden from the known risk factors of musculoskeletal disorders.

    Methods

    GBD 2013 covers 188 countries, 7 super-regions and 21 regions from 1990 to 2013. In total, 306 causes of diseases and injuries, 240 causes of death and 79 risk factors were systematically analysed. Details on the methodology of GBD studies and the main changes to the methods for GBD 2013 have been explained in previous publications.2 ,19–21

    There are 22 countries in the EMR by WHO designation with different levels of Gross National Income per capita. The low-income countries are Afghanistan, Djibouti, Somalia and Yemen; middle-income countries: Egypt, Iraq, Iran, Jordan, Lebanon, Libya, Morocco, Pakistan, Palestine, Sudan, Syria and Tunisia; and high-income countries: Bahrain, Saudi Arabia, Kuwait, Oman, Qatar and the United Arab Emirates.

    In GBD 2013, the burden from six main categories of musculoskeletal disorders was calculated: rheumatoid arthritis, osteoarthritis, low back pain, neck pain, gout and other musculoskeletal disorders. We used the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) codes or their equivalent codes in the earlier versions of ICD and assumed different sequelae for each disorder (table 1). Each musculoskeletal disorder had a list of sequelae with potentially different levels of disability; for instance, low back pain had eight sequelae classified as mild, moderate, severe and most severe low back pain with or without leg pain. Range of disability weight for these sequelae was different from 0.02 (95% uncertainty interval (UI) 0.011–0.035) for mild low back pain without leg pain to 0.384 (95% UI 0.256–0.518) for most severe low back pain with leg pain. A complete list of health state descriptions and equivalent disability weights is available in the web appendix of a previous GBD publication.21

    View this table:
    Table 1

    Musculoskeletal disorders, equivalent ICD-10 codes and list of sequelae for each disorder in the Global Burden of Disease Study

    In this study, the burden is described as prevalence, deaths, years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs) and disability-adjusted life-years (DALYs). We calculated crude and age-standardised rates to be able to distinguish the difference in population structure from the difference in age-specific and sex-specific rates.

    Most of the musculoskeletal disorder categories (except rheumatoid arthritis and the category of ‘other musculoskeletal disorders’) were assumed to be non-fatal with no mortality and no YLLs due to premature mortality. To estimate the cause-specific deaths, all-cause mortality envelopes (total number of deaths due to any cause) were estimated for each country during the period of 1990–2013. All accessible data from vital registration systems, sibling history surveys, sample registration data and household recall of deaths were considered for preparing these envelopes. Cause of death data was extracted from the same sources, as well as any available verbal autopsies.19 We used cause of death ensemble modelling 22 to estimate the number of deaths from rheumatoid arthritis and ‘other musculoskeletal disorders’ by age, sex, country and year.

    To estimate morbidity, we updated the GBD 2010 systematic reviews of epidemiological measures for each musculoskeletal disorder. We used different strategies to avoid missing sources of data, which included sharing of the results of systematic reviews with the extensive network of GBD collaborators.21 A list of GBD 2013 data citations is available on the Global Health Data Exchange tool (http://ghdx.healthdata.org/gbd-2013-data-citations). A series of Bayesian meta-regression analyses through DisMod-MR 2.0 were used for disease modelling. We used fixed effects for study-level and country-level covariates to adjust input data. As an example of study-level covariates, we included studies with standard OA disease definition as the reference standard and adjusted extracted data from other studies that define OA based on ‘reporting having had a diagnosis of OA’, ’radiographic diagnosis of OA regardless of symptoms’ or ‘OA with symptoms but no radiographic confirmation’. More details on covariates are available in the online appendix of a previous publication.21 Model-based epidemiological estimates in combination with disability weights were used to calculate cause-specific YLDs for each age, sex, location and calendar year.21 DALYs were calculated through summation of YLLs and YLDs.

    We calculated attributable burden of the following risk factors from the total burden of musculoskeletal disorders: occupational ergonomic factors, high body mass index and low glomerular filtration rate. Details on definitions of these risk factors and their relative risk for musculoskeletal disorders are available in the web appendix of a previous publication.20

    We have reported 95% UIs for each quantity in this analysis. The UIs are based on taking 1000 samples of posterior distribution and report the 25th and 975th values of the distribution.21

    Results

    The number of deaths due to musculoskeletal disorders in EMR increased from 1706 (95% UI 1380–2090) in 1990 to 5084 (95% UI 3794–5869) in 2013, a 198% increase. Age-standardised death rate was 0.89 per 100 000 (95% UI 0.74–1.15) in 1990 and 1.39 per 100 000 (95% UI 1.07–1.58) in 2013. The number of deaths in 2013 was equal to 0.83 crude deaths per 100 000 (95% UI 0.62–0.95) and constitutes 0.14% (95% UI 0.10–0.16) of all deaths. YLLs of musculoskeletal disorders increased from 68 211 (95% UI 52 961–86 586) in 1990 to 183 659 (95% UI 131 166–219 907) in 2013, a 169% increase.

    Web appendix table S1 shows point prevalence of musculoskeletal disorders in the EMR countries. Low back pain was the most common condition in all countries in 2013, except Kuwait and Lebanon where neck pain was more prevalent: the range of point prevalence of low back pain was between 32.45 per 1000 in Kuwait and 159.23 in Egypt. The range of point prevalence of neck pain was between 34.31 per 1000 in Pakistan and >55 per 1000 in Somalia and Djibouti. Osteoarthritis ranged from 29.67 per 1000 in Pakistan to >46 per 1000 in Somalia and Djibouti. Point prevalence of gout had a range of 0.15 per 1000 in Pakistan to 1.00 per 1000 in Iran and Qatar. Point prevalence of rheumatoid arthritis was between 0.88 per 1000 in Saudi Arabia and >3 per 1000 in Somalia and Djibouti (web appendix table 1). YLDs of musculoskeletal disorders increased from 1279 per 100 000 (95% UI 907–1686) in 1990 to 1576 (95% UI 1111–2100) in 2013. Musculoskeletal disorders were the second leading cause of YLDs after ‘mental and substance use disorders’ and accounted for 15.7% of all YLDs (95% UI 13.8–17.7%) in 2013. Low back pain and neck pain had the highest YLDs among the disorders (web appendix 1).

    supplementary web appendix table

    As expected, YLDs were the main component of DALYs for musculoskeletal disorders (>98%, both in 1990 and 2013), and DALY estimates were very close to YLD estimates. The total burden of musculoskeletal disorders was 4 842 603 DALYs (95% UI 3 450 654–6 359 159) in 1990 and increased to 9 946 874 DALYs (95% UI 7 068 174–13 194 791) in 2013, a 105.4% increase in total DALYs of musculoskeletal disorders, compared with a 58.0% increase in the rest of the world. The crude DALYs rate per 100 000 increased from 1297.1 (95% UI 924.3–1703.4) in 1990 to 1606.0 (95% UI 1141.2–2130.4) in 2013, which shows a 23.8% increase. Age-standardised DALY rates were 2055.6 (95% UI 1478.3–2704.1) in 1990 and increased by 2.9% to 2115.9 (95% UI 1517.2–2799.7) in 2013. The burden of musculoskeletal disorders as a proportion of total DALYs has constantly increased since 1990; the proportion that was 2.4% (95% UI 1.7–3.0) in 1990 increased to 3.2% (95% UI 2.8–4.6) in 2000 and 4.7% (95% UI 3.6–5.8) in 2013. Figure 1 compares the burden of musculoskeletal disorders in the EMR to data for the world, low/middle-income countries and high-income countries. Table 2 summarises DALY rates for each musculoskeletal disorder. As shown, DALY rates have been increased during 1990–2013 for all musculoskeletal disorders, both in men and women.

    View this table:
    Table 2

    Crude rates of disability-adjusted life-years (per 100 000) for musculoskeletal disorders in the Eastern Mediterranean Region, 1990 and 2013

    Figure 1
    Figure 1

    Burden of musculoskeletal disorders in the Eastern Mediterranean Region compared with the world, high-income countries and developing countries, 2013. DALYs, disability-adjusted life-years.

    Egypt had the highest and Lebanon had the lowest age-standardised musculoskeletal disorders DALY rates both for males and females. Ranges of age-standardised DALY rates had a considerable overlap between the low-income, middle-income and high-income countries of EMR (table 3).

    View this table:
    Table 3

    Age-standardised disability-adjusted life year rates (per 100 000) of musculoskeletal disorders by country and sex in the Eastern Mediterranean Region, 2013

    DALY rates had a clear increasing pattern with age; however, those of middle age had the highest number of DALYs (figure 2). Among different musculoskeletal disorders, low back pain had the highest proportion of DALYs in all age groups. The proportion of osteoarthritis DALYs out of total DALYs of musculoskeletal disorders increased with age. In individuals aged ≥65 years, osteoarthritis was the second important cause of DALYs after low back pain.

    Figure 2
    Figure 2

    Age-specific rates and numbers of disability-adjusted life-years (DALYs) of musculoskeletal disorders in the Eastern Mediterranean Region, 2013.

    The burden of musculoskeletal disorders was higher in females compared with males, except for low back pain and gout. The total burden was 5 415 756 DALYs (95% UI 3 877 474–7 150 503) in females and 4 531 118 DALYs (95% UI 3 200 432–6 026 689) in males in 2013. DALY rates were 1800.9 (95% UI 1289.4–2377.7) and 1422.2 (95% UI 1004.5–1891.6) in females and males, respectively. Figure 3 shows the burden of each musculoskeletal disorder by sex in 2013. Gout had a small burden (0.6 and 1.7 DALYs per 100 000 in women and men, respectively) and its burden has not been shown in the figure.

    Figure 3
    Figure 3

    The burden of musculoskeletal disorders in the Eastern Mediterranean Region by sex, 2013. DALYs, disability-adjusted life-years.

    The ratio of age-standardised female to male musculoskeletal DALY rates ranged between 1.02 in Morocco and 2.01 in Iran (table 3). The ratio of age-standardised female to male DALY rates was <1 for gout disease in all countries of the region. For low back pain, the ratio was <1 except for Sudan (1.02), Egypt (1.03), Saudi Arabia (1.15), Lebanon (1.43) and Iran (1.76). Except the above-mentioned cases, for each country disorder, the ratio of age-standardised female to male DALY rates was >1.

    Occupational ergonomic factors and high body mass index were the most important risk factors for musculoskeletal disorders. Around 1 545 221 (95% UI 1 023 600–2 148 137) DALYs of low back or neck pain were attributable to occupational ergonomic factors and 436 766 DALYs (95% UI 283 614–626 896) of its burden were attributable to high body mass index. Moreover, 462 676 DALYs (95% UI 313 110–642 108) of osteoarthritis burden were attributable to high body mass index. Occupational ergonomic factors were the most important risk factor in men, while high body mass index was a more important factor in women: the attributable burden to occupational ergonomic factors was 3.2 times of the attributable burden to high body mass index in men and 0.8 for women. This ratio had a range of 4.3–12.3 in the low-income countries of the region, 0.7–6.4 in the middle-income countries and 0.8–1.5 in the high-income countries of the region.

    Discussion

    This study shows high prevalence and burden of musculoskeletal disorders, especially for low back pain, neck pain and osteoarthritis in the region. The burden of these disorders has increased in the EMR more than the rest of the world during 1990–2013. Although the increase in burden is mainly related to increase in population size and ageing, despite most of the other diseases, there was no decrease in the age-standardised rates of burden. The proportion of musculoskeletal disorders' burden over total burden of disease has even increased. Musculoskeletal disorders are the second leading cause of disability in the EMR. Although population ageing is a main reason for increasing burden of musculoskeletal disorders, a large proportion of the burden is imposed on people in their most active and productive years of life. We did not find a specific association between income level of the country and burden of musculoskeletal disorders; however, the relative importance of risk factors (occupational ergonomic factors compared with high body mass index) was different based on the income level of countries.

    Our findings call for incorporating prevention and control programmes for musculoskeletal disorders in national health programmes. COPCORD could be used as a stepwise approach to address the high burden of musculoskeletal disorders; however, previous COPCORD programmes in EMR usually have not progressed beyond the early stages (such as baseline surveys) towards a focus on prevention and control activities.6 ,23 Considering the important risk factors of musculoskeletal disorders, public education, occupational health and safety and ergonomics are among the most important components of any prevention and control programme. Medical interventions and rehabilitation to preserve functional status are essential to provide control of the situation.

    Advocacy is required to raise the attention of policy and decision makers to the disease burden caused by musculoskeletal disorders.3 As a reflection on the previous round of the ongoing GBD study, some experts recommended extensive involvement of the local community to initiate any intervention for control of musculoskeletal disorders and integrating services with existing policies and structures.3 Mody and Brooks suggested new models of care and strategies to train community health workers and primary healthcare providers to detect and initiate the management of patients at earlier stages.24

    The education of patients and the entire population, treatment with cost-effective interventions, prevention through identification and reduction of environmental and genetic risks are the main components of interventions after primary epidemiological assessments.23 ,25 People with musculoskeletal conditions are exposed to a spectrum of services including traditional, complementary and alternative therapies of which efficacies may not always be clear.26 Recent biological medications and surgical approaches are changing the long-term outcomes of some musculoskeletal disorders such as rheumatoid arthritis or severe osteoarthritis; however, they can be too expensive to be affordable in all countries.27 Timely access to healthcare providers is important for some of the musculoskeletal disorders. For instance, in patients with inflammatory disorders such as rheumatoid arthritis, early assessment by a specialist improves the prognosis.28 However, previous studies show that many individuals with musculoskeletal disorders do not receive treatment in EMR countries; in Lebanon, around a quarter of these individuals seek some kind of treatment.26 On the other hand, there is a high risk of using unnecessary diagnostic or therapeutic procedures for people with musculoskeletal symptoms, especially in the wealthier countries. This needs to be avoided through proper planning for quaternary prevention.

    Modification of lifestyle factors (such as maintaining physical fitness and ideal weight, having a balanced diet, avoidance of smoking and excess alcohol consumption, and preventing injuries) is not only beneficial for musculoskeletal health but also for other non-communicable diseases that contribute to increasing mortality and morbidity.24

    Low back pain and neck pain have the highest burden of musculoskeletal disorders in most of the EMR countries. In previous studies, the seven-day period prevalence of pain for dorsolumbar and cervical spine in Iran were 23.7% and 14.2%, respectively.7 The estimates were higher in rural areas compared with urban areas, and also in people with specific jobs and pregnant women.29 In Kuwait, the point prevalence of low back pain in schoolchildren aged 10–18 years old was 20.6% in males and 39.3% in females.30 A cumulative prevalence of around 28% for low back pain was reported by children aged 11–19 years old in Tunisia.31 Some of these estimates cannot be directly compared with our estimates due to different definitions and the time interval used for assessment. However, the available evidence collectively reflects the importance of the problem. There are several evidence-based public health and clinical guidelines for low back pain32–34 and neck pain,35 ,36 usually from high-income countries. Development of suitable guidelines for use in resource-poor settings is challenging. Most research evidence originates from high-income countries and may not be relevant or applicable to the needs of low-income countries. Moreover, the development of valid clinical guidelines needs resources and certain expertise that sometimes is not available. In the paucity of nationally developed guidelines, EMR countries can use the available guidelines through adaptation processes.37

    Osteoarthritis is an important cause of disability, especially in elderly people. It is expected to be influenced by the population ageing process more than other musculoskeletal disorders. Some evidence suggests that intensive physical activity might increase risk of osteoarthritis in large joints; however, this is not a general conclusion.38 Findings on association of physical activity and osteoarthritis are especially confusing in the elderly; while some studies suggest that walking and physical exercise has a deleterious effect on osteoarthritis, there are some reviews that show aerobic exercises in elder individuals can help to reduce symptoms of knee osteoarthritis.39 Light or moderate physical activities are not usually known to increase risk or complications of osteoarthritis. Physical activity can also decrease risk of osteoarthritis through reducing body mass index.38 ,39 The burden of ‘other musculoskeletal disorders’ was around threefold in women compared with men. Conditions such as fibromyalgia and connective tissue disorders are more prevalent among women.7 ,8

    Our study has some limitations. Although we estimated a collective burden for musculoskeletal disorders in this study, we did not provide separate estimations for some of the disorders such as spondylopathies and systemic connective tissue disorders. Moreover, we did not separately assess the burden of hand osteoarthritis. Our classification of musculoskeletal disorders does not have a distinction between symptoms, complaints and diseases; however, ICD-10 codes clarify the components of each category. We did not include osteoporosis as a disease; instead, low bone mineral density was classified as a risk factor for fractures, so its attributable burden has not been shown in this paper. Finally, we did not provide separate estimates for diseases such as the Behçet disease, which have regional importance in EMR or individual (but not collective) high burden.

    There were issues with availability and quality of data in some EMR countries; however, we used GBD modelling approaches to reduce this issue. Indeed, the lack of high-quality data in the region, especially from the 1990s, might have an influence on the estimated trend of musculoskeletal diseases. Although this issue exists for many of the causes of diseases, it might have an imbalanced effect on musculoskeletal diseases (the importance of which has been highlighted in the recent decades) compared with the other diseases. This factor might affect different regions of the world in different ways. However, we do not believe that it can purely explain the faster increase in burden of musculoskeletal disorders in EMR compared with the rest of the world.

    Conclusion

    Findings from this study show a high burden of musculoskeletal disorders, especially low back pain, neck pain and osteoarthritis in the region. The reasons for faster increase of musculoskeletal disorders' burden in EMR during 1990–2013 compared with the rest of the world need to be explored. Our findings call for integrating prevention and control programmes for musculoskeletal disorders with health system programmes. Plans should include improving health data to monitor trends, addressing known risk factors especially through health education and awareness, ergonomics and occupational health and safety, and providing evidence-based early diagnosis and treatment, rehabilitative care and community programmes to increase knowledge of risk and protective factors.

    Acknowledgments

    The authors acknowledge Pauline Kim at the Institute for Health Metrics and Evaluation, Seattle, WA, for editing this paper.

    References

    1. ↵
      2. Woolf AD ,
      3. Akesson K
      . Understanding the burden of musculoskeletal conditions. The burden is huge and not reflected in national health priorities. BMJ 2001;322:1079–80.
      OpenUrlFREE Full Text
    2. ↵
      2. Murray CJL ,
      3. Barber RM ,
      4. Foreman KJ , et al
      ., with GBD 2013 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet 2015;386:2145–91. doi:10.1016/S0140-6736(15)61340-X
      OpenUrlCrossRefPubMed
    3. ↵
      2. Hoy DG ,
      3. Smith E ,
      4. Cross M , et al
      . Reflecting on the global burden of musculoskeletal conditions: lessons learnt from the global burden of disease 2010 study and the next steps forward. Ann Rheum Dis 2015;74:4–7. doi:10.1136/annrheumdis-2014-205393
      OpenUrlAbstract/FREE Full Text
    4. ↵
      2. Hoy D ,
      3. Geere JA ,
      4. Davatchi F , et al
      . A time for action: opportunities for preventing the growing burden and disability from musculoskeletal conditions in low- and middle-income countries. Best Pract Res Clin Rheumatol 2014;28:377–93. doi:10.1016/j.berh.2014.07.006
      OpenUrl
    5. ↵
      2. Chopra A ,
      3. Abdel-Nasser A
      . Epidemiology of rheumatic musculoskeletal disorders in the developing world. Best Pract Res Clin Rheumatol 2008;22:583–604. doi:10.1016/j.berh.2008.07.001
      OpenUrlCrossRefPubMed
    6. ↵
      World Health Organization, International League of Associations for Rheumatology. COPCORD Website. http://copcord.org/information.asp (accessed 4 Apr 2016).
    7. ↵
      2. Davatchi F ,
      3. Sandoughi M ,
      4. Moghimi N , et al
      . Epidemiology of rheumatic diseases in Iran from analysis of four COPCORD studies. Int J Rheum Dis 2016;19:1056–62. doi:10.1111/1756-185X.12809
      OpenUrl
    8. ↵
      2. Chaaya M ,
      3. Slim ZN ,
      4. Habib RR , et al
      . High burden of rheumatic diseases in Lebanon: a COPCORD study. Int J Rheum Dis 2012;15:136–43. doi:10.1111/j.1756-185X.2011.01682.x
      OpenUrlCrossRefPubMed
    9. ↵
      2. Al-Awadhi AM ,
      3. Olusi SO ,
      4. Moussa M , et al
      . Musculoskeletal pain, disability and health-seeking behavior in adult Kuwaitis using a validated Arabic version of the WHO-ILAR COPCORD Core Questionnaire. Clin Exp Rheumatol 2004;22:177–83.
      OpenUrlPubMedWeb of Science
    10. ↵
      2. Farooqi A ,
      3. Gibson T
      . Prevalence of the major rheumatic disorders in the adult population of north Pakistan. Br J Rheumatol 1998;37:491–5. doi:10.1093/rheumatology/37.5.491
      OpenUrlAbstract/FREE Full Text
    11. ↵
      2. Davatchi F ,
      3. Jamshidi AR ,
      4. Tehrani Banihashemi A , et al
      . Effect of ethnic origin (Caucasians versus Turks) on the prevalence of rheumatic diseases: a WHO-ILAR COPCORD urban study in Iran. Clin Rheumatol 2009;28:1275–82. doi:10.1007/s10067-009-1235-7
      OpenUrlPubMed
    12. ↵
      2. Davatchi F ,
      3. Jamshidi AR ,
      4. Banihashemi AT
      . WHO-ILAR COPCORD pilot study in Tehran, Iran. J Rheumatol 2006;33:1714.
      OpenUrlFREE Full Text
    13. ↵
      2. Davatchi F ,
      3. Tehrani Banihashemi A ,
      4. Gholami J , et al
      . The prevalence of musculoskeletal complaints in a rural area in Iran: a WHO-ILAR COPCORD study (stage 1, rural study) in Iran. Clin Rheumatol 2009;28:1267–74. doi:10.1007/s10067-009-1234-8
      OpenUrlPubMed
    14. ↵
      2. Akhter E ,
      3. Bilal S ,
      4. Kiani A , et al
      . Prevalence of arthritis in India and Pakistan: a review. Rheumatol Int 2011;31:849–55. doi:10.1007/s00296-011-1820-3
      OpenUrlPubMed
    15. ↵
      2. Badsha H ,
      3. Kong KO ,
      4. Tak PP
      . Rheumatoid arthritis in the United Arab Emirates. Clin Rheumatol 2008;27:739–42. doi:10.1007/s10067-007-0782-z
      OpenUrlPubMed
    16. ↵
      2. Ismail AI ,
      3. Al-Abdulwahab AH ,
      4. Al-Mulhim AS
      . Osteoarthritis of knees and obesity in Eastern Saudi Arabia. Saudi Med J 2006;27:1742–4.
      OpenUrlPubMed
    17. ↵
      2. Pountain G
      . The prevalence of rheumatoid arthritis in the Sultanate of Oman. Br J Rheumatol 1991;30:24–8. doi:10.1093/rheumatology/30.1.24
      OpenUrlAbstract/FREE Full Text
    18. ↵
      Palestinian Central Bureau of Statistics. Press conference on the initial survey results: demographic and health survey. Ramallah-Palestine, 2004. http://www.pcbs.gov.ps/Portals/_pcbs/PressRelease/dhsurvey_04e.pdf (accessed 8 Feb 2017).
    19. ↵
      GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117–71. doi:10.1016/S0140-6736(14)61682-2
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      2. Forouzanfar MH ,
      3. Alexander L ,
      4. Anderson HR , et al
      ., with GBD 2013 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:2287–323. doi:10.1016/S0140-6736(15)00128-2
      OpenUrlCrossRefPubMed
    21. ↵
      Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:743–800. doi:10.1016/S0140-6736(15)60692-4
      OpenUrlCrossRefPubMed
    22. ↵
      2. Foreman KJ ,
      3. Lozano R ,
      4. Lopez AD , et al
      . Modeling causes of death: an integrated approach using CODEm. Popul Health Metr 2012;10:1. doi:10.1186/1478-7954-10-1
      OpenUrlCrossRefPubMed
    23. ↵
      2. Darmawan J
      , World Health Organization-International League of Associations for Rheumatology Community Oriented Program for Control of Rheumatic Disease. Recommendations from the Community Oriented Program for Control of Rheumatic Disease for data collection for the measurement and monitoring of health in developing countries. Clin Rheumatol 2007;26:853–7. doi:10.1007/s10067-007-0553-x
      OpenUrlCrossRefPubMed
    24. ↵
      2. Mody GM ,
      3. Brooks PM
      . Improving musculoskeletal health: global issues. Best Pract Res Clin Rheumatol 2012;26:237–49. doi:10.1016/j.berh.2012.03.002
      OpenUrlCrossRefPubMed
    25. ↵
      2. Woolf AD ,
      3. Brooks P ,
      4. Akesson K , et al
      . Prevention of musculoskeletal conditions in the developing world. Best Pract Res Clin Rheumatol 2008;22:759–72. doi:10.1016/j.berh.2008.07.003
      OpenUrlCrossRefPubMed
    26. ↵
      2. Slim ZN ,
      3. Chaaya M ,
      4. Habib RR , et al
      . High burden of musculoskeletal conditions: a problem that has only recently come to recognition. Chronic Illn 2011;7:311–20. doi:10.1177/1742395311420611
      OpenUrlCrossRefPubMed
    27. ↵
      2. Guillemin F ,
      3. Carruthers E ,
      4. Li LC
      . Determinants of MSK health and disability—social determinants of inequities in MSK health. Best Pract Res Clin Rheumatol 2014;28:411–33. doi:10.1016/j.berh.2014.08.001
      OpenUrlCrossRef
    28. ↵
      2. Rudan I ,
      3. Sidhu S ,
      4. Papana A , et al
      ., Global Health Epidemiology Reference Group (GHERG). Prevalence of rheumatoid arthritis in low- and middle-income countries: a systematic review and analysis. J Glob Health 2015;5:010409. doi:10.7189/jogh.05.010409
      OpenUrl
    29. ↵
      2. Mousavi SJ ,
      3. Akbari ME ,
      4. Mehdian H , et al
      . Low back pain in Iran: a growing need to adapt and implement evidence-based practice in developing countries. Spine 2011;36:E638–46. doi:10.1097/BRS.0b013e3181fa1da2
      OpenUrlPubMed
    30. ↵
      2. Shehab D ,
      3. Al-Jarallah K ,
      4. Al-Ghareeb F , et al
      . Is low-back pain prevalent among Kuwaiti children and adolescents? A governorate-based study. Med Princ Pract 2004;13:142–6. doi:10.1159/000076953
      OpenUrlPubMed
    31. ↵
      2. Bejia I ,
      3. Abid N ,
      4. Ben Salem K , et al
      . Low back pain in a cohort of 622 Tunisian schoolchildren and adolescents: an epidemiological study. Eur Spine J 2005;14:331–6. doi:10.1007/s00586-004-0785-2
      OpenUrlCrossRefPubMed
    32. ↵
      Guidance on the prevention and management of musculoskeletal disorders (MSDs) in the workplace. Health Saf Exec Northen Irel 2015. https://www.hseni.gov.uk/publications/guidance-prevention-and-management-musculoskeletal-disorders-msds-workplace (accessed 5 Apr 2016).
    33. ↵
      National Institute for Health and Clinical Excellence. Low back pain in adults: early management, NICE guidelines [CG88]. https://www.nice.org.uk/guidance/cg88 (accessed 5 Apr 2016).
    34. ↵
      2. Delitto A ,
      3. George SZ ,
      4. Van Dillen LR , et al
      ., Orthopaedic section of the American Physical Therapy Association. Low back pain. J Orthop Sports Phys Ther 2012;42:A1–57. doi:10.2519/jospt.2012.0301
      OpenUrlPubMed
    35. ↵
      Work Loss Data Institute. National Guideline Clearinghouse | Neck and upper back (acute & chronic). 2013. https://www.guideline.gov/content.aspx?id=47589 (accessed 7 Apr 2016).
    36. ↵
      2. Hegmann K
      . National Guideline Clearinghouse | Cervical and thoracic spine disorders. 2011. https://www.guideline.gov/content.aspx?id=35207 (accessed 7 Apr 2016).
    37. ↵
      2. Rashidian A
      . Adapting valid clinical guidelines for use in primary care in low and middle income countries. Prim Care Respir J 2008;17:136–7. doi:10.3132/pcrj.2008.00055
      OpenUrlCrossRefPubMed
    38. ↵
      2. Fransen M ,
      3. Simic M ,
      4. Harmer AR
      . Determinants of MSK health and disability: lifestyle determinants of symptomatic osteoarthritis. Best Pract Res Clin Rheumatol 2014;28:435–60. doi:10.1016/j.berh.2014.07.002
      OpenUrl
    39. ↵
      2. Jones G ,
      3. Winzenberg TM ,
      4. Callisaya ML , et al
      . Lifestyle modifications to improve musculoskeletal and bone health and reduce disability—a life-course approach. Best Pract Res Clin Rheumatol 2014;28:461–78. doi:10.1016/j.berh.2014.07.004
      OpenUrl

    Footnotes

    • Handling editor Tore K Kvien

    • Contributors MM-L and AHM prepared the first draft. All other authors provided data, developed models, analysed data, reviewed results, provided guidance on methodology and/or reviewed the manuscript. MM-L and AHM finalised the draft based on comments from other authors’ feedback. MM-L, AHM, AA and MHF responded the comments of reviewers. AHM and CJLM accept full responsibility for the work, have access to the data and controlled the decision to publish.

    • Funding The global burden of disease study was funded by the Bill and Melinda Gates Foundation.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.