Reducing arthritis pain through physical activity: a new public health, tiered approach

IS THERE A FEASIBLE SOLUTION?

This enormous problem of arthritis and multimorbidities comes at a time of unprecedented need for and demand upon NHS services, coupled with a historic financial challenge. Care for people with long-term conditions needs to move towards personalised, integrated systems of care, with emphasis on supported self-management, for example, through care and support planning, and shared decision making.⁹ The NHS Five Year Forward View articulated the challenges to the NHS in supporting the increasingly complex health needs of an ageing society.¹⁰ This led to multiple initiatives linking health, social care, and public health approaches including local devolution experiments, and the creation of the sustainability and transformation partnerships.

There are limited treatment options for the GP supporting a patient with arthritis and back pain. Although pharmacotherapies are commonly used, their toxicities are considerable, especially in the context of multimorbidity.^11,12 However, there is increasing doubt about their efficacy, and overmedicalisation is an important barrier to self-management.¹³ Muscle-strengthening and activity-related exercises are very effective in reducing osteoarthritis and back pain, and improve everyday functioning and mobility; there are few adverse side effects and many potential additional benefits, for example, cardiovascular, mental health, and overall wellbeing;¹⁴ this approach is supported by systematic literature reviews and NICE recommendations.^15,16 Though physical activity programmes are widely available, these often do not meet the needs of people with painful musculoskeletal problems. Also, such programmes have often not been part of a coordinated local approach, building on community assets.

Given their prevalence, impact, and the underpinning risk factors amenable to relatively simple activity interventions, a comprehensive public health approach to painful musculoskeletal conditions is therefore warranted.

A NEW PUBLIC HEALTH, TIERED APPROACH

Providing Physical Activity Interventions for People with Musculoskeletal Conditions is a new report to support local commissioners and providers of health and wellbeing services, including NHS and local authorities, in taking action to improve musculoskeletal health locally.¹⁷ It was co-produced by Arthritis Research UK, the Department of Health, Public Health England, and NHS England; it has been endorsed by the Royal College of General Practitioners, the Chartered Society of Physiotherapy, and the Local Government Association. It provides information and practical solutions for local physical activity provision, includes a focused checklist to enable local decision makers to map, and highlight any gaps in, current levels of physical activity provision. The report reviews the extensive and well-established benefits of physical activity both for people with musculoskeletal conditions and wider society. At the heart of the report is a tiered approach (Figure 1) providing a framework to support people with these conditions to benefit from physical activity.

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Figure 1.

Commissioning physical activity provision for people with musculoskeletal conditions.

Many people with reasonable mobility can benefit from self-directed physical activity using accessible community facilities, so long as staff are aware of, and facilities equipped for, the needs of people with musculoskeletal conditions. Others will benefit from supervised physical activity, including land-and water-based exercise groups, such as T’ai Chi, pilates, walking groups, or aqua aerobics.

There are a number of principles underpinning the higher-tiered interventions. Improving muscle strength is a basic construct: if someone can’t undo a jar or get out of a chair easily, they have significant muscle weakness and it will be fruitless expecting them to join a walking group. They will need a much more structured approach, akin to cardiac or pulmonary rehabilitation. One such approach for lower-limb joint pain is the ESCAPE-pain programme, a 6-week, 12-visit intervention, which provides both self-management principles and supervised instruction in appropriate leg-strengthening exercises. It has been demonstrated not only to be effective in terms of pain and functioning outcomes in clinical trials, but also to be cost-effective in the UK setting. Of course, some people will need individualised supervised support with prescribed exercises from physiotherapists.

Which tier is appropriate for a given individual? This needs to be a shared decision between the person with arthritis or back pain and those supporting them, who can be any care provider including GPs, allied health professionals, health trainers, fitness professionals, or peers. People’s personal preferences are important and their physical activity provision needs vary over time as their health changes. All this must be supported by local systems for behaviour change.

A PRESCRIPTION FOR BETTER MUSCULOSKELETAL HEALTH

Conceptually the idea of increasing physical activity is not new, but this joined-up approach is. This is not about a whole new programme of work, but it is about making sure that local physical activity provision meets the needs of people with arthritis and back pain. This will take time, but here are some things we can all do now:

• produce and maintain up-to-date lists of local physical activity opportunities and contacts for each tier that can be shared with colleagues and patients;

• when seeing people with arthritis and back pain, promote physical activity as a way to improve symptoms;

• develop local services, such as health trainers,¹⁸ or care and support planning, which can signpost people to local physical activity services in the tier that meets their needs and personal preferences; and

• engage local authority and clinical commissioners to adopt a public health approach,¹⁹ undertaking local review of musculoskeletal health need and ensuring physical activity provision in line with this report, particularly ensuring access to ESCAPE-pain.