by Dr Adam Al-Kashi, Head of Research & Education, BackCare
In his 1985 paper – Sick Individuals and Sick Populations (1) – epidemiologist, Professor Geoffrey Rose rendered a crucial insight, “The more widespread a particular cause, the less it explains the distribution of cases. The hardest cause to identify is the one that is universally present”. Despite decades of evidence, policy and best intention, a musculoskeletal health crisis has emerged and escalated to the point of now warranting its very own world summit. Earlier this month, we witnessed the inaugural MSK World Summit and the unveiling of a public health agenda for musculoskeletal health. Delegates from thirty countries converged to partake in representations from regional, national and international level advisors and keynoters. Let us be clear, this is indeed good news, but we’re not home and dry yet. We’re here because the way we’ve been working has not been working. In many ways, we have become part of the problem, and without deep change, further resource burn can only deliver more of the same. The MSK World Summit has awakened the stakeholder map. We must now bear on with the remedial journey and navigate the uncharted public health terrain.
Some believe the answer lies firmly in ‘2.0’ social softwares and their ‘Smart’ hardware counterparts. But whilst an app can persuade you to eat an apple and then tell Facebook about it, isn’t there more to public health than cajoling a seemingly health-indifferent population through the hoops? Cue the culture change argument. Or perhaps internal and external solutions – culture and systems – are not opposites, rather correlates. After all, anyone who doubts that technology can change culture need only visit almost any public space on the planet to witness the infiltration and impact of Smartphones. At the end of the day, when all is said and done, history repeats itself and this is no less than a classic conundrum. Our global musculoskeletal health crisis is irreducibly yet inseparably ingrained in both our culture and our systems, from which sustainable change must co-emerge. But if technology is the medium, what’s the message? What is the nature and locus of a new culture that animates demonstrably more healthful behaviours as perhaps supported or even driven by new technologies?
Addressing musculoskeletal health through public health affords unique opportunities not otherwise accessible via the primary care route. Let’s take a look at common user case: John has acute back pain so he visits his GP who only now detects the psychological states and traits well-evidenced to accurately predict long-term pain and disability (yellow flags et al.). Indeed, psychological factors are the most consistent predictors of acute musculoskeletal pain, transition to chronic pain and poor self-management thereafter. Put simply, psychological stress causes the biomechanical body to behave more symptomatically. Common sense tells us that back pain is a physical problem, but it’s not time for common sense, or industry trend, or expert opinion.
It’s time for hard evidence:
- “Psychological distress was the only factor found to have a pre-existing influence on new episodes of lower back pain” in 694 Australian nurses over 4 years (2).
- Burnout (feeling frustrated and emotionally exhausted by work) doubled the risk of future back pain amongst 1,704 Israeli workers over 3 years (3).
- Lack of decision control and leadership quality predicted future back pain amongst 2,808 Norwegian workers over 2 years (4).
- Personality inventory of 2,323 American college students in the 1960s predicted mid-life chronic pain diagnosis in the 1990s (5).
These are powerful precedents which have been reassuringly reflected through the work and words of many who contributed to the MSK World Summit. NHS England’s Dr Martin McShane put it most memorably when he said, “the soft stuff is the hard stuff.”
However, this kind of evidence has not to date been widely integrated by clinicians, policymakers and academics. Perhaps the biggest opportunity of public health is to impact that universally present cause, and hold accountable the institutional health culture that has constructed the societal health culture we seek so desperately to change. May the efforts of this new global community continue. Our battle against the world’s leading cause of disability is at stake.