Anthony D. Woolf

A systematic review of the global prevalence of low back pain

OBJECTIVE To perform a systematic review of the global prevalence of low back pain, and to examine the influence that case definition, prevalence period, and other variables have on prevalence. METHODS We conducted a new systematic review of the global prevalence of low back pain that included general population studies published between 1980 and 2009. A total of 165 studies from 54 countries were identified. Of these, 64% had been published since the last comparable review. RESULTS Low back pain was shown to be a major problem throughout the world, with the highest prevalence among female individuals and those aged 40-80 years. After adjusting for methodologic variation, the mean ± SEM point prevalence was estimated to be 11.9 ± 2.0%, and the 1-month prevalence was estimated to be 23.2 ± 2.9%. CONCLUSION As the population ages, the global number of individuals with low back pain is likely to increase substantially over the coming decades. Investigators are encouraged to adopt recent recommendations for a standard definition of low back pain and to consult a recently developed tool for assessing the risk of bias of prevalence studies.

Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement

OBJECTIVE In the course of performing systematic reviews on the prevalence of low back and neck pain, we required a tool to assess the risk of study bias. Our objectives were to (1) modify an existing checklist and (2) test the final tool for interrater agreement. STUDY DESIGN AND SETTING The final tool consists of 10 items addressing four domains of bias plus a summary risk of bias assessment. Two researchers tested the interrater agreement of the tool by independently assessing 54 randomly selected studies. Interrater agreement overall and for each individual item was assessed using the proportion of agreement and Kappa statistic. RESULTS Raters found the tool easy to use, and there was high interrater agreement: overall agreement was 91% and the Kappa statistic was 0.82 (95% confidence interval: 0.76, 0.86). Agreement was almost perfect for the individual items on the tool and moderate for the summary assessment. CONCLUSION We have addressed a research gap by modifying and testing a tool to assess risk of study bias. Further research may be useful for assessing the applicability of the tool across different conditions.

Measuring the global burden of low back pain

Low back pain is a major cause of morbidity in high-, middle- and low-income countries, yet to date it has been relatively under-prioritised and under-funded. One important reason may be the low ranking it has received relative to many other conditions included in the previous Global Burden of Disease studies, due in part to a lack of uniformity in how low back pain is defined and a paucity of suitable data. We present an overview of methods we have undertaken to ensure a more accurate estimate for low back pain in the Global Burden of Disease 2005 study. This will help clinicians to contextualise the new estimates and rankings when they become available at the end of 2010. It will also be helpful in planning further population-based epidemiological studies of low back pain to ensure their estimates can be included in the future Global Burden of Disease studies.

Overcoming challenges in order to improve the management of rheumatic and musculoskeletal diseases across the globe

The challenges faced in improving the prevention and management of rheumatic and musculoskeletal diseases (RMDs) across the globe are addressed in the inaugural White Paper from the World Forum on Rheumatic amd Musculoskeletal Diseases (WFRMD) published in this issue [1]. The WFRMD, convened by Dr Mustafa Al Maini, brings together leaders from the international rheumatological community who are committed to promoting collaborative strategies to deal with this burden and work with major organisations such as ILAR, ACR, EULAR, PANLAR and AFLAR and policy makers such as theWorld Health Organisation (WHO). It is an important and timely initiaitive to increase awareness of the major burden that rheumatic and musculoskeletal diseases have on individuals and society and to explore opportunities to address these challenges on a local and global scale. This is the mission of WFRMD (www.wfrmd.org). It fits within the context of the Global Alliance for Musculoskeletal Health which the Bone and Joint Decade has brought together to call for action by policy makers to deal with the burden of RMDs (http://bjdonline.org). Musculoskeletal health is essential to independent living and self-sustainability as well as enabling people to keep physically active and reduce the risk of non-communicable diseases. It is threatened by a wide range of RMDs at all stages of life. Other risks such as obesity, injuries related to occupation and sports and more serious trauma such as falls and road injuries can often result in musculoskeletal disability. These RMDs are often long term and are an important comorbidity amongst the chronic diseases we accumulate as we age. An RMD as a comorbidity magnifies the physical disability that people suffer [2]. All these factors affecting musculoskeletal health along with the ageing of populations result in the great and growing prevalence and disability across the globe [3]. Further, exacerbating these trends is the growing need for people, as they age, to be able to continue to contribute economically to society with delayed retirement ages becoming commonplace inmany countries around the world. Health and social care systems are struggling to cope with ageing populations and their multimorbidity. For these reasons, there is an urgency to deal with the challenges of rheumatic and musculoskeletal diseases, challenges which are not currently being addressed by policies and priorities of health systems around the globe [4]. Indeed, RMDs are not considered a major noncommunicable disease by the WHO [5] or UN [6]. As a consequence, there is great and growing avoidable disability. The Bone and Joint Decade has responded by bringing together all stakeholders—professional, scientific and patient organisations as a Global Alliance for Musculoskeletal Health calling for action by decision makers to implement policies to deal with this burden (http://bjdonline.org/call-for-action/). The specific challenges and opportunities for the rheumatology community have been considered by the inaugural meeting of the World Forum on Rheumatic and Musculoskeletal Diseases on the 26th of September in Abu Dhabi and are reported in this issue [1]. Subsequent papers are planned to address issues raised in the White Paper. This is much needed as the expert community must propose solutions for the decision makers to deal with these challenges. The burden of RMDs on individuals and societies is now well documented [3, 7–15], and there are many evidenceA. D. Woolf (*) Global Alliance for Musculoskeletal Health of the Bone and Joint Decade, University of Plymouth Peninsula College of Medicine and Dentistry, Plymouth, England, UK e-mail: anthony.woolf@btopenworld.com

How to achieve and enhance professionalism in rheumatology

Ensuring and maintaining professionalism in medicine is essential, but there are many challenges to the traditional values and methods of achieving this. It is important for the specialty of rheumatology to highlight the importance of professionalism within training and clinical practice and to encourage ways of demonstrating this to patients, public, providers and politicians to gain confidence and avoid over-regulation. Professional attitudes, virtues and behaviour are key to providing the best standards of care for the large and growing number of people with musculoskeletal conditions, in particular, those that are long term. This is important not only for those who are directly in our care but also for those in the community, where the civic aspects of professionalism are central, by generally improving the standards of care through education and by raising priority. The tradition of knowing and working closely with our patients and their organisations is an important way of acquiring, maintaining and demonstrating professionalism within the specialty.

Is teriparatide or alendronate the best treatment for glucocorticoid-induced osteoporosis?

BACKGROUND Secondary osteoporosis develops in approximately half of all patients who receive glucocorticoid therapy. International guidelines recommend treatment with bisphosphonates; however, it has also been suggested that treatment with recombinant human parathyroid hormone (PTH) might be beneficial. The two therapies have never been compared for their capacity to increase bone mineral density (BMD) in the context of a randomized controlled trial.