Healthcare Service Improvement Team
Primary and secondary prevention ofchronic musculoskeletal pain
Author:Norma Prosser, Dr Mary Webb, Public Health Specialists
Date:11June 2010 / Version:1
Publication/ Distribution:
- Public (Internet)
Review Date: A review of this document is not planned by Public Health Wales NHS Trust.
Purpose and Summary of Document:
The document has been produced to assist local health boards to implement the Commissioning Directive on Arthritis and Chronic Musculoskeletal Conditions, and should be read in conjunction with that publication.
This is an evidence-based summary of effective interventions for primary and secondary prevention of chronic musculoskeletal pain.
No effective interventions have been identified from the available evidence.
Work Plan reference: HS02
Date: 11 June 2010 / Version:1 / Page: 1 of 8
Public Health Wales / Primary and secondary prevention of chronic musculoskeletal pain
CONTENTS
1Background
2Chronic musculoskeletal pain
2.1Introduction
2.2Search methodology
2.3Prevalence
2.4Hospital admissions
3Primary prevention
4Secondary prevention
5Further information
6References
©2010 Public Health Wales NHS Trust.
Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context.
Acknowledgement to Public Health Wales NHS Trust to be stated.
1Background
This document has been produced to assist local health boards to implement the Welsh Assembly Government’s,Designed for people with chronic conditions.Service development and commissioning directives.Arthritis and chronic musculoskeletal conditions1, and should be read in conjunction with that publication.
A key action identified in chapter 2, Prevention – reducing the risks (p.9)of the publicationis evidence-based primary and secondary prevention1. From the key categories identified in the commissioning directive (p.2), the aim in this document is the identification of currently available information and evidence-based literature with a focus on chronic musculoskeletal pain.
To supplement the evidence–base, and provide an overview of the topic, information with regard to prevalence (where available); hospital admissions (where information is available from Patient Episode Database Wales - PEDW); and links to additional information resources have been included. The links to further information resources is included to indicate where additional details, or management and treatment guidance can be sought.
The information contained in this document is not exhaustive.
2Chronic musculoskeletal pain
2.1Introduction
Chronic musculoskeletal pain (CMP) is generally identified as a musculoskeletal pain condition that has no identifiable underlying serious or specific disorder and has not resolved in less than 3 to 6 months2.
2.2Search methodology
Search terms used: primary prevention, secondary prevention, musculoskeletal pain
Search terms were kept broad to maximise retrieval of literature and search limits set to retrieve papers published between January 2003 to January 2010.
Electronic databases: Medline; Embase; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; Cochrane Central Register of Controlled Trials and British Nursing Index.
Meta search engines: Turning Research Into Practice (TRIP); Google Scholar; SUMsearch.
Websites: NHS Evidence; International Network of Agencies for Health Technology Assessment (INAHTA); National Institute for Health and Clinical Excellence (NICE); National Horizon Scanning Centre and Map of Medicine; UpToDate.
2.3Prevalence
Musculoskeletal pain is very likely in an individual’s lifetime affecting 1 in 4 adults, and is a common source of serious long-term pain and physical disability2.
Regional musculoskeletal pain can be defined as pain of short or long duration, localised to one body region, such as wrist, arm, knee, shoulder3.
By self-report, 10-30% of the population have had shoulder pain that lasted more than one week in the previous month, 5-10% report elbow pain and 5-15% report hand pain. About 10% of people have forearm pain at any one time. Even more report shoulder pain that lasted more than one day in the previous month. Lower limb pain is equally common and may have a large impact on mobility. Up to 15% of people have disabling foot and ankle pain at any one time, and this is often associated with regional musculoskeletal pain elsewhere3.
In adolescents, estimates of prevalence vary according to age, case definition of pain and method of data collection. In young adolescents, as many as 53% may have experienced musculoskeletal pain at some time in their lives, and about 15% have persistent musculoskeletal pain at least once a week4.
Both physical and psychosocial factors appear to be risksassociated with musculoskeletal pain2. High levels of psychological distress, repetitive movements of the limb, undue forceful movements, monotonous work, and lack of autonomy at work appear to be factors associated with chronic musculoskeletal pain3.
Recreational activity is considered an important contributor to the physical causes in the onset of CMP. Therefore advice may conflict with current initiatives to increase physical activity as a means of controlling obesity3.
2.4Hospital admissions
Figure 1: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of pain not classified elsewhere (ICD-10:R52) by Unitary Authority
Source: PEDW
Figure 2: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of pain not classified elsewhere (ICD-10:R52) by Local Health Board
Source: PEDW
Table 1: Persons admitted to hospital in Wales 2000-2006 with a principal diagnosis of pain not classified elsewhere (ICD-10:R52)
Local Health Board / Unitary Authority / AdmissionsBetsiCadwaladrUniversity / Isle of Anglesey / 258
Gwynedd / 291
Conwy / 153
Denbighshire / 102
Flintshire / 216
Wrexham / 97
Powys / Powys / 114
Hywel Dda / Ceredigion / 109
Pembrokeshire / 55
Carmarthenshire / 353
Abertawe Bro Morgannwg / Swansea / 185
Neath Port Talbot / 96
Bridgend / 157
Cardiff and ValeUniversity / Vale of Glamorgan / 114
Cardiff / 290
Cwm Taf / Rhondda Cynon Taff / 222
Merthyr Tydfil / 36
Aneurin Bevan / Caerphilly / 123
Blaenau Gwent / 52
Torfaen / 73
Monmouthshire / 93
Newport / 115
Total / 3304
Source: PEDW
3Primary prevention
Maintaining a healthy lifestyle including monitoring weight and diet, risks acquired through the workplace,recreational activity, and lifestyle choices are conducive to overall health and well being2.
The origin of CMP may occur in adolescence and studies have investigated the risk factors so that approaches for primary prevention may be explored. There is some observational evidence that for primary prevention purposes, school healthcare professionals should pay attention to pre-teens and early adolescents practising vigorous exercise (predictor of traumatic pain), reporting headache (predictor of non-traumatic pain) and reporting day-time tiredness (predictor of both types of pain)4.
There is preliminary data of the association between low birth weight and chronic musculoskeletal pain5, and preliminary observational evidence demonstrating that chronic musculoskeletal pain is associated with falls in the elderly6.
The primary prevention of CMP has not as yet, proved feasible, and modern management approaches are not directed towards cure, but aim to prevent unnecessary disability and minimise morbidity2, 3.
Published standards of care note2, 3:
- people are not always aware of how to reduce the risk of developing chronic musculoskeletal pain. Information should be widely available which is evidence-based and emphasises a safe approach to physical fitness and weight reduction and encourages the adoption of a healthy lifestyle;
- health promotion campaigns have been shown to be effective in promoting messages about maintaining musculoskeletal health. Campaigns should inform people how to identify persistent symptoms which they should report to appropriate health care professionals. These messages are likely to have the greatest impact when they are positively promoted by everyone involved or interested in the problem of regional musculoskeletal pain, including employers, education and health service providers, leisure services and voluntary organisations.
4Secondary prevention
Published standards of care recommend2, 3:
- people with regional musculoskeletal pain should be regarded as equal and active partners in their healthcare; need good information; and be empowered to take responsibility for their musculoskeletal health;
- people should have access to self management and education programmes, including the Expert Patient Programme.
5Further information
Arthritis and Musculoskeletal Alliance (ARMA)
- Standards of care for people with regional musculoskeletal pain
Map of Medicine
- Complex regional pain syndrome (CRPS) – specialist care;
NICE
- Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy): diagnosis and management of CFS/ME in adults and children.CG53. 2007.
6References
- Welsh Assembly Government. Designed for people with chronic conditions. Service development and commissioning directives. Arthritis and chronic musculoskeletal conditions.Cardiff: WAG; 2007. Available at: 25th Nov 2009]
- WalshNEet al.Standards of care for acute and chronic musculoskeletal pain: the bone and joint decade (2000-2010).Arch Phys Med Rehabil 2008; 1830-45. Available at: [Accessed 25th Nov 2009]
- Arthritis and Musculoskeletal Alliance. Standards of care for regional musculoskeletal pain. London: ARMA; 2007. Available at: 25th Nov 2009]
- El-Metwally A et al.Risk factors for development of non-specific musculoskeletal pain in preteens and early adolescents: a prospective 1-year follow-up study. BMC Musculoskelet Disord 2007; 8: 46. Available at: [Accessed 25th Nov 2009]
- Mallen C et al. Is Chronic musculoskeletal pain in adulthood related to factors at birth? A population-based case-control study of young adults.Eur J Epidemio 2006; 21: 237-43
- Leveille SG et al.Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA2009; 302:2214-21
Date: 11 June 2010 / Version:1 / Page: 1 of 8