Disease makes moving painful
MUSCULOSKELETAL CONDITIONS Arthritis and related musculoskeletal conditions affect up to one in five people in the UK, causing pain, disability, reduced quality of life and costing society billions, as Judy Hobson reports
Arthritis currently affects ten million people in the UK with 8.5 million suffering from osteoarthritis. Six million are in constant pain with 1.5 million claiming disability living allowance. Although osteoarthritis can develop in people from their thirties onwards it is most frequently seen in older people. The number of people with osteoarthritis increases from one in five people in their fifties, to one in two in their eighties.
At its most severe, the condition makes the simplest of activities, such as getting out of a chair or climbing the stairs, difficult.
Osteoarthritis is caused by the loss of the cartilage that normally lines the inner surfaces at the ends of bones inside the joints. Being overweight puts extra stress on weight-bearing joints, making pain and stiffness worse.
“We’re seeing a lot more osteoarthritis because people are living longer,” says Professor David Isenberg, academic director of rheumatology at University College London. “If everyone over 70 was X-rayed, you’d see evidence of it in all of them, but that doesn’t mean they’d all have pain and stiffness.
“There seems to be a combination of elements that contribute to whether someone has pain and stiffness – one is genetic, the other occupational. For example, we see it in the knees and hips of people who have put extra stress on their joints during their lifetime.
“You’re also much more likely to be affected if you’re obese. Damaged knees will hurt more if you’re carrying around 20 stones rather than ten.”
Painkillers, such as paracetamol, are used to manage the pain along with exercise and weight loss. Non-steroidal anti-inflammatory drugs (NSAIDs) are used to reduce swelling, while some people may get some pain relief from anti-inflammatory creams or gels. Steroid injections can help, but are used sparingly because of side effects, such as bone damage.
Professor Isenberg says patients often eventually turn to surgery. “When pain wakes someone up every night, there’s no alternative to joint replacement,” he says.
Figures from the National Joint Registry show the number of knee and hip operations went up during the four years from 2006 to 2010. In 2009-10, there were 84,527 knee replacements compared with 68,500 in 2006-7, while hip replacements rose from 65,000 in 2006-7 to 79,413 in 2009-10.
However, a recent report in GP magazine based on a Freedom of Information request, shows joint replacement procedures are being restricted in 59 per cent of primary care trusts (PCTs) to cut costs. This means patients in some areas are being left in pain for long periods before getting a replacement knee or hip.
This can make their condition worse, says Joe Dias, president of the British Orthopaedic Association, who points out: “Patients needing hip and knee replacements gain less benefit from surgery if they’re made to wait as delay results in further deterioration.”
The NHS’ own Atlas of Variation in Healthcare for 2009-10 shows dramatic differences in access to these operations across England. Much of the variation cannot be explained by population health needs, and highlights shortcomings in the quality and value of services in different areas.
Ministers have promised to come down hard on PCTs who ration joint replacement operations. Health Minister Simon Burns says: “If local health bodies stop patients from having treatment on the basis of cost alone we will take action against them. Decisions on suitability for surgery should be made by clinicians based on what is most clinically appropriate for the patient and taking the individual patient’s needs into account. No right-thinking person can understand how anyone could delay a patient’s treatment unnecessarily.”
By comparison rheumatoid arthritis is much less common. Around 580,000 people in the UK have rheumatoid arthritis and three times as many women as men. The disease destroys the synovial membrane – a thin layer of protective cells around the joints – causing swelling, pain, loss of strength in the joints and fatigue.
Rheumatoid arthritis usually starts in the wrists, hands and feet. The symptoms usually start when people are aged between 35 and 55, and it is thought to be triggered by a virus.
Rheumatoid arthritis is an autoimmune disease, which means it is caused by the body’s immune system attacking its own cells. Professor Isenberg says: “It’s as if your body suddenly starts conspiring against you. Instead of the white blood cells in your immune system protecting you, they start attacking the synovial membrane inside your joints. Female hormones interact with the immune system and we believe this is why it’s more common in women.”
Though it’s uncommon for arthritis to be the cause of bone and joint pain in young children, they can be affected. Juvenile idiopathic arthritis affects around one in 1,000 children. While there is no cure, the symptoms can be managed so children can enjoy an active life and become an independent adult.
Drugs called disease modifying anti-rheumatic drugs (DMARDs) can slow down the progression of arthritis, and NSAIDs can help with the swelling and pain. In the last decade newer drugs called biologics have emerged. These target particular molecules and cells responsible for driving the disease.
But a report by the Policy Analysis Centre found access to biologics in England is limited and that there is a “lack of will” to tackle the burden of rheumatoid arthritis in Europe.
Tom Hockley, co-author of the report, says: “This lack of will is most evident in England, where access to modern biologic therapies is heavily restricted until a patient’s burden of disease has become severe.”
The analysis found that 6 per cent of patients were on biologics in England, compared with 8 per cent in Spain, 11 per cent in Sweden and 12 per cent in the Netherlands.
While the National Institute for Health and Clinical Excellence (NICE) recommends biologics when patients have not responded to conventional therapies, there is variation in prescribing across the country.
Professor Isenberg says: “It’s unfortunate but there are elements of a postcode lottery. In spite of NICE’s recommendation that biologics should be prescribed if a patient has failed to respond to two conventional therapies, we’re finding some PCTs are putting barriers in the way. All PCTs should adhere to the guidance so that people with rheumatoid arthritis can get these drugs as soon as they need them.”
Bone and joint health is important for keeping bones strong and preventing fragility fractures. Every year in the UK there are 300,000 fragility fractures. Of these, 89,000 are hip fractures. Some 13,800 people with a fracture hip die within a year, and half of those who survive will no longer be able to live independently and be in constant pain.
Figures from the National Osteoporosis Society show that by 2036 there could be 140,000 hospital admissions a year for hip fractures as a result of the ageing population and increasingly unhealthy lifestyles. The bill could top £6 billion.
Our bones are constantly being broken down and replaced with new cells. When we are young, we make more bone cells than we lose, but in our thirties we start to lose bone mass. Over time this thins and weakens the bones and causes osteoporosis.
In women this loss is accelerated after the menopause because they no longer produce oestrogen. For women, the lifetime risk of a hip fracture due to osteoporosis is one in six – greater than their one-in-nine risk of developing breast cancer.
Professor Roger Francis, from the Institute for Ageing and Health at Newcastle University, says: “While the decline in oestrogen levels after the menopause puts women at risk of osteoporosis, drinking, smoking and a sedentary lifestyle are putting more men at risk. By the age of 50, men have a one-in-five risk of fracture.”
Drugs called oral bisphosphonates can slow down the rate of bone loss. But worryingly, almost 40 per cent of PCTs are either under-prescribing osteoporosis drugs or are failing to provide services which could prevent people with osteoporosis from having another fracture.
Professor Francis says: “Only 50 per cent of those who have had a fragility fracture are being assessed or getting treatment. The situation has changed little over the last few years. Some PCTs are still under-prescribing and failing to recognise the seriousness of this disease. We need a systematic approach to ensure those who’ve had a fragility fracture are assessed immediately.”