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The ShARP Musculoskeletal Report

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All tied up in knots: New report exposes the truth behind Britain’s musculoskeletal health

All tied up in knots: New report exposes the truth behind Britain’s musculoskeletal health

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  • 1. All tied up in knots New report exposes the truth behind Britain’s musculoskeletal health
  • 2. 2
  • 3. Contents Page Foreword: What works for an age old problem? 2 Section 1: Fairer sex face an unfair burden 4 Section 2: Time takes a toll 6 Section 3: Body of evidence 8 Section 4: As stiff as a board 10 Section 5: Simply the best approach 13 About Simplyhealth 16 Did you know: Stats and facts from ShARP 18
  • 4. Foreword: What works for an age old problem? Every year in the UK 20% of the population present with a new onset or recurrence of a musculoskeletal problem.1 In fact, musculoskeletal disorders (MSDs) are the most common work related problem in Europe2, the most common cause of physical disability3 and the biggest reason for long term treatment.4 Musculoskeletal disorders can affect the body’s muscles, ligaments, tendons, nerves and joints, and most commonly result in back pain, knee pain, neck and shoulder pain, hip and limb pain. A recent study5 into how we manage our musculoskeletal health reveals that two out of five Britons believe that by resting, their musculoskeletal condition will improve, what they don’t realise is that it could in fact be making it worse. Studies have shown that rest intensifies and prolongs back pain, reduces mobility and extends recovery time.6 2 1 2 3 4 5 A poll of 1,000 people who suffer aches and pains commissioned by the Simplyhealth Advisory Research Panel (ShARP), found that more than a third (35%) take to their beds in the hope it will ease their pain. Exercise, such as yoga7 and workouts guided by a physiotherapist,8 is proven to improve spinal aches and pains, but only 6% of sufferers use it to relieve their symptoms and almost half (42%) say pain prevents them from exercising as much as they would like. Team GB kayaker, sports scientist and physiotherapist, Paul Hobrough from ShARP notes: “There is a real danger that people can become trapped in a vicious cycle with lack of exercise leading to increased stiffness, pain and muscle wastage and therefore less support for the spine and an increased risk of problems. Clarke A & Symmons D. The burden of rheumatic disease. Medicine 2006; 34 (9): 333-335 European Agency for Safety and Health at Work Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003;81:646-56. European Opinion Research Group EEIG. Health, Food and Alcohol and Safety. Special Eurobarometer 186. European Commission, 2003 One Poll survey of 1,000 people carried out in June 2013
  • 5. “On top of that, reduced activity increases the likelihood of weight gain which places even more stress on our joints. The evidence is clear; those suffering from chronic low back pain benefit from exercise and often get worse with prolonged periods of inactivity.” Being overweight is a key contributor to a lot of muscle and joint pain, affecting many of the weight-bearing joints. One long term study found that obesity increases the risk of osteoarthritis of the knee by a factor of four.9 Given the global epidemic of obesity it is perhaps not surprising that the incidence of arthritis of the knee climbed by 22% from 1990 to 2005 and continues to rise.10 A weighty link The new study by ShARP has also revealed a link between weight and back pain, with almost all (99.5%) of those weighing 14 stone or more reporting problems. Pain hot spots The ShARP study identified the lower back as the nation’s number one sore spot, with seven out of ten (70%) respondents reporting problems in this region. But worryingly, three out of four sufferers do not ask for professional advice on musculoskeletal problems, with more than a third (36%) of those who do not seek help saying the cost of care puts them off. Another major barrier is the mistaken belief that a doctor’s referral is needed to see a physiotherapist.11 The following report, brought to you by ShARP, explores the area of back pain and general muscle, bone and joint problems. It looks at who suffers and why; the impact of our body shape, weight and height and how age too, as well as suffering in silence, can make our musculoskeletal health worse. The report also suggests how we can treat muscle, bone and joint problems quickly and conveniently. 6 http://www.ncbi.nlm.nih.gov/pubmed/7823996 7 http://www.nhs.uk/news/2011/11November/Pages/yoga-improves-back-pain-says-research.aspx 8 http://www.bmj.com/content/319/7205/279 9 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291123/ and http://bjp.sagepub.com/content/early/2013/04/08/2049463713484296.full 10 http://lowerextremityreview.com/article/knee-oa-in-obese-patients-a-cyclical-clinical-challenge 11 In some areas of the UK you need to see a GP for referral but if you go privately no referral is needed 3
  • 6. Section 1: Fairer sex face an unfair burden Women experience more acute back pain than men, 25% compared to 20%, and are more prone to knee problems, with one in three (33%) reporting pain in these joints compared to one in five men (22%). Women tend to turn to physical treatments such as physiotherapy, chiropractic and massage, with more than half (54%) of those questioned for the Simplyhealth Advisory Research Panel survey reporting they use one of these approaches to relieve back pain, compared to just over a third (39%) of men. However, women are also most likely to risk exacerbating their back pain problems by resting, 38% take to their beds compared to 30% of males. Men are three times more likely to do nothing to help their back pain and simply hope their pain goes away, 12% put their heads in the sand and suffer compared to just 4% of the women surveyed. 4 12 http://www.eurekalert.org/pub_releases/2013-05/kp-luo051013.php Painkillers are preferred by women, with: ✔ over half (57%) taking them to relieve back pain, compared to fewer than half (43%) of men — which is just as well as there is evidence that long term use of prescription painkillers increases the risk of erectile dysfunction.12 Peak pain times Pain and stiffness peak at the start and at the end of the day for both sexes, but the pattern is more pronounced in women: ✔ 18% of women reported problems in the morning, compared to 12% of men ✔ 16% of respondents said they suffer more in the evening, compared to 10% of men. Both sexes try to soldier on and manage chores around the house and garden on their own, but men are the most likely to employ someone to help out — 16% compared to 10%.
  • 7. Sadness and moods Depression associated with joint pain is an issue for both men and women, with 28% of women and 23% of men saying aches affect their mood, although women are most at risk of feeling a sense of frustration: ✔ almost a third (27%) of women reported their musculoskeletal problems leave them feeling helpless, compared to 17% of men ✔ two out of five (40%) women complained they feel old before their time, compared to one in four (25%) men. 5
  • 8. Section 2: Time takes a toll Back pain becomes more common as we age, with the ShARP study revealing that 99% of over 50s with joint problems reporting they get it in the back. Pain and stiffness doubles with age, with more than one in three (36%) of those aged over 55 reporting daily discomfort compared to just 15% of those aged 25 to 30. Neck and shoulder problems peak earlier. Two out of five under 35 year olds suffer neck pain and almost a third (30%) report shoulder problems, while for the over 55s the figures were just 17% and 30%. The increased time younger respondents spend staring at screens is probably a factor behind neck and shoulder pain. The growth in technology and working hours has had a big impact on the younger generation. Around half of under 30s sit at a computer for more than six hours a day (51%), play games on a console or mobile device (50%) or watch two hours of more television a day (47%), compared to an average across all ages of 40%, 30% and 40% respectively. 6 13 http://bestpractice.bmj.com/best-practice/monograph/337.html Asking for help Over 55s are most willing to ask their GP for help, with a third (33%) visiting their doctor for advice, compared to a quarter of those under the age of 40. The benefits of physiotherapy are most often recognised by under 40s, with almost one in five (19%) turning to a physiotherapist for treatment, compared to 15% of over 40s. Painkillers are most commonly used by over 50s, with two out of three (63%) resorting to them for back pain — despite the known risks of long term use of non steroidal anti-inflammatory drugs (NSAIDs) such as aspirin.13 Oral NSAIDs are associated with a slightly elevated risk of heart attack or stroke and they are not recommended for anyone with a history of cardiac problems, high blood pressure or diabetes — which are all more common in this age group.
  • 9. Dr Gill Jenkins, GP and expert from ShARP, notes: “Overthe-counter painkillers can be very useful, particularly for acute episodes, but it is not wise to take them for long periods without consulting your GP, particularly if you have any underlying problems. “Hypertension increases with age, as does the incidence of diabetes and heart disease and it is important that people with persistent aches and pains discuss their options with a GP, physiotherapist or other health professional.” Curiously, the survey revealed that among those with back pain the youngest and oldest age groups are the least likely to employ someone to help in the home or garden, with just one in ten (10%) of under 30s and a similar number of over 55s (11%) taking someone on to help with household chores compared to almost a quarter (23%) of those aged 31 to 35. 7
  • 10. Section 3: Body of evidence Our build shapes our experience of joint and muscle pain and the ShARP study adds to the growing body of evidence that obesity is a major contributor to the rising rates of back and knee pain. ✔ obesity was associated with higher rates of daily discomfort, which was reported by almost half (47%) of those in the heaviest group, compared to just 15% of those in the lightest The latest meta-analysis, a type of super study which examines all the relevant published evidence, has shown a clear association between being overweight or obese and an increased incidence of lower back pain,14 and obesity has been identified as the single most common cause of preventable osteoarthritis of the knee.15 ✔ more than a third (33%) of those weighing 14 stone or more reported knee pain — almost twice the number (19%) who were 9.5 stone or less Comparable trends emerged from the survey: ✔ more than four out of five (86%) of those weighing more than 14 stone reported problems with lower back pain ✔ almost all (92%) those weighing in excess of 17 stone admitted it was an issue 8 Obesity and joint pain is a bad combination, as pain often limits physical activity, which increases weight gain and puts even more pressure on already painful joints. The ShARP survey confirmed this cycle may already be a reality for many Britons. An additional risk factor is that around half (48%) of those weighing 14 stone or more rest to relieve their pain, compared to an average of around a third (35%) who weigh less. 14 http://www.ncbi.nlm.nih.gov/pubmed/20007994 15 http://www.arthritistoday.org/where-it-hurts/knee-pain/knee-care/lose-weight-knee-pain.php
  • 11. Stature also has an affect on musculoskeletal pain and the study suggests lower back pain affects nine out of ten (90%) people who are 6ft or taller, compared to an average of seven out of ten (70%) who are under 6ft. Height tends to trigger problems around the neck and shoulders, with three quarters (75%) of those who are 6ft 4 or more reporting problems, 50% higher than the average (51%). However, this group also reported spending more time at a computer, with seven out of ten (71%) saying they are hunched over a screen for more than six hours a day, almost twice the average (40%). 9
  • 12. Section 4: As stiff as a board While our backs are the number one pain and problem gripe, stiffness, and muscular aches and pains are also a big issue too and it is no wonder so many of us feel that our bodies are just one giant knot. ✔ 22% of the ShARP study’s respondents suffer from stiffness, aches and pains daily ✔ 14% suffer from stiffness or aches and pains weekly ✔ 10% suffered from stiffness or aches and pains at least once a month While some of us suffer daily, weekly or monthly from stiffness or aches and pains, exercise (for 14%), gardening (13%) and sleeping awkwardly (13%) cause muscular problems for those of us that are not common sufferers of musculoskeletal problems. Age and weight too has a part to play when it comes to musculoskeletal pain. The ShARP survey revealed that: ✔ those that are aged 45 or more tend to suffer daily ✔ respondents who weighed over 14 stone were much more likely to suffer daily pain, while generally those who were under nine stone had intermittent pain Pain that stops play Musculoskeletal body pain also seems to prevent sufferers from getting on with an active life, from causing havoc with exercise plans, impacting on general lifestyles, to not being able to wear high heels any more. Stats and facts reveal that: ✔ 32% of sufferers complained they could not do as much exercise due to the pain ✔ just under a quarter (24%) said they could not lift things ✔ 20% of respondents could not walk for long periods of time 10
  • 13. ✔ 14% had given up wearing high heels ✔ 9% said that such musculoskeletal pain had a huge impact on their lifestyles meaning they were unable to play with their children or climb stairs Pain that makes you feel long in the tooth While musculoskeletal pain stops many from carrying on as usual, muscle, bone and joint pain also makes people feel older and more depressed. Worse still one in four in the ShARP study said that as a result they were worried about their future health and 23% felt helpless in dealing with the pain. Body pain also has an effect on people’s love life too, with 14% admitting to feelings of anger and 13% saying they were less interested in their romantic relationships as a result of the pain. 11
  • 14. Blame factors Other blame culprits Twenty-three per cent of those suffering from musculoskeletal issues blame their work environment where they remain in the same position for lengthy periods and 16% claim the chair they had at work was a factor. ✔ just over one third (34%) thought that musculoskeletal pain was an inevitable part of ageing And while most of us associate exercise as being good for our health, when it comes to musculoskeletal pain the opposite was thought to be true as 20% blamed weight bearing exercise for causing musculoskeletal problems, so they tended to avoid it. Again greater education is needed on the care for musculoskeletal health as weight bearing exercises have been shown in research as being very good for joint health. ✔ diet and genetic factors were considered to have an influence by 30% and 22% respectively on muscle, bone and joint pain Suffering in silence Many of us it seems suffer from poor musculoskeletal health and over 50% of us admit to doing nothing to help our musculoskeletal health on a day-to-day basis. This is despite many of us being fully aware of what exercises keep our musculoskeletal health in good shape: ✔ swimming, mentioned by two thirds of respondents as being the best exercise for musculoskeletal health ✔ yoga (43%) ✔ pilates (40%) 12
  • 15. Section 5: Simply the best approach It is unlikely that we can completely avoid aches and pains, but we do have the power to reduce their impact on daily life. Physiotherapist Paul Hobrough says: “Prevention, timely treatment and on going advice from a health professional can all make a real difference in terms of heading off problems and taking control when an issue arises. Ensuring the sufferer gets high quality advice from a recognised health professional as early as possible is the key to reducing long term suffering and costly absence from the workforce. “Watching our weight and getting plenty of exercise are both essential for optimum musculoskeletal health, but there is increasing evidence that good nutrition is also a major weapon against the ravages of age related wear and tear.” Dr Gill Jenkins explains: “We have known for a long time that calcium is incredibly important for healthy bones and the better our intake in childhood and the teenage years, the better our lifetime bone density. *Up to annual limits “Vitamin D is essential to prevent rickets in childhood, but it is less well known that deficiency — which is common during UK winters — is associated with bone pain in adults. And new evidence is emerging all the time about the role of other nutrients including protein, folate and vitamin B12 in maintaining musculoskeletal health.” Don’t suffer in silence There is clear evidence that when pain strikes, prompt action and professional advice can speed recovery and reduce the risk of long term dependence on painkillers. But sadly, this study reveals that thousands of Britons with back pain and other aches and pains are not accessing the care that could make a difference. Many admit they are concerned about the cost of treatment. With a health cash plan from Simplyhealth you can claim back the cost of visiting a physiotherapist, chiropractor or osteopath* and focus on getting the right treatment without being worried about how much it will cost. 13
  • 16. The company, which was founded 140 years ago has a philosophy which is as straightforward as its name: “In a world where so many people can’t be bothered, we’re proud to be the ones that can. “We believe in helping people access affordable healthcare and delivering exceptional personal customer service.” As a result of that commitment, it now boasts more than four million customers and eight out of ten would recommend Simplyhealth to family and friends. Last word… Aches and pains associated with our body’s skeleton and muscles are a fact of life for hundreds of thousands of people living in the UK and back pain alone will affect four out of five of us at some time in our lives.16 Problems get worse as we age, with around five million people over the age of 65 suffering some degree of discomfort.17 14 A report by the British Pain Society and Help the Aged found: “Older people are more at risk of pain than other sections of the population, but less likely than younger people to experience good pain management.” Some experts are also concerned about the negative impact of ongoing changes to the National Health Service and a recent Health Select Committee report warned: “The reorganisation process continues to complicate the push for efficiency gains. Although it may have facilitated savings in some cases, we heard that it more often creates disruption and distraction.”18 As a result, in this period of change and confusion, it is more important than ever for people with musculoskeletal problems to take control of their own health. It is becoming increasingly evident that the NHS may no longer be able to support all of our healthcare needs and some local services are already being reduced. Pain control and physiotherapy — our most effective weapons against 16 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx 17 http://www.britishpainsociety.org/book_pain_in_older_age_ID7826.pdf 18 http://www.publications.parliament.uk/pa/cm201012/cmselect/cmhealth/1499/149906.htm Paragraph 63
  • 17. musculoskeletal problems — are being targeted as a result of government cutbacks meaning that patients could now be waiting for six months or more to see an NHS physiotherapist.19 This can not only exacerbate pain and disability, but it also increases the risk of depression and other emotional factors. People suffering from musculoskeletal problems shouldn’t just soldier on or suffer in silence as the problem will just get worse. Seeking professional support in the first instance means that sufferers will have a clear path to managing their musculoskeletal health problems. Many people do not realise they don’t need a referral from a GP to see a physiotherapist20 who can help with the pain management approaches associated with our body’s skeleton but more importantly treat the problem. There are many affordable options today allowing greater access to medical specialists, all of which can help sufferers deal with issues fast and in many cases resolve the problem. So for those people who do not enjoy the best of ‘skeleton and muscular health’ seek advice and help now, don’t suffer in silence. ShARP 19 In some areas of the UK the waiting time can be several months to six months: http://www.guardian.co.uk/society/2011/oct/07/nhs-cuts-physiotherapy-patients 20 In some areas of the UK you need to see a GP for referral but if you go privately no referral is needed 15
  • 18. About Simplyhealth We’ve been helping people access affordable healthcare for 140 years. Our range of health cash plans, dental plans, private medical insurance and self funded health plans help individuals, families and businesses. We are committed to providing excellent personal customer service and doing the right thing for our customers. We recently won the Customer Commitment Award at the UK Customer Satisfaction Awards, organised by the Institute of Customer Service. Our health cash plans and dental plans help people claim money back towards the cost of everyday healthcare, including check-ups, treatment and emergencies. Our private medical insurance helps individuals and families access treatment at a time and place convenient to them. We are the UK’s largest health cash plan provider and one of the UK’s top five private medical insurance providers. We cover nearly four million people with health plans (more than any other company) and 20,000 businesses choose us as their healthcare provider. 16 We became Simplyhealth in 2009 after bringing together BCWA, HealthSure, HSA, LHF and Totally Active. In 2011 we acquired Denplan, the UK’s leading dental payment plan specialist. Denplan will continue to operate as a standalone business. Simplyhealth Independent Living helps people get the most out of life through mobility products and daily living aids. We have specialist Independent Living centres in Andover, Bristol, Manchester and Leeds, plus partner stores in Ipswich, Salford and Colchester. We carry out free home assessments to find the right mobility product for our customers. We have always followed mutual values and care about our communities. Last year we donated £1.6m to health related charities and good causes. In a world where so many people can’t be bothered, we’re proud to be the ones that can.
  • 19. For more information on any aspect of Simplyhealth, visit: www.simplyhealth.co.uk. ShARP is funded by Simplyhealth. 17
  • 20. Did you know: Stats and facts from ShARP Arthritis is the most common cause of musculoskeletal problems in the UK. More than 10 million people a year consult a doctor about arthritis and more than one in three people over the age of 50 has pain which interferes with their normal activities.21 Back pain will affect four out of five people at some time in their lives and more than six million people in the UK suffer from chronic back pain.22 It is estimated to cost £1.6billion a year in GP consultations, hospital admissions and other healthcare expenditure.23 Calcium is essential for strong, healthy bones. Dairy foods are rich in calcium in a readily absorbed form.24 A pint of semi-skimmed milk provides 690mg of calcium, almost all the entire daily intake of 700mg an adult needs. Depression is a problem for many people with musculoskeletal conditions. Three out of five people with the condition feel depressed when their pain is at its worst.25 18 Endorphins are chemicals in the body produced in the pituitary gland which damp down pain, but people with rheumatoid and psoriatic arthritis have lower than average levels, which makes it harder to cope with the condition.26 Fibromyalgia is a long term condition which causes widespread pain, is thought to affect one in 20 people and is usually diagnosed between the ages of 30 and 60.27 Good nutrition is not only important for general health, there is now evidence it can reduce muscle wasting as we age. Protein, vitamin B12, folic acid and vitamin D are all helped to preserve muscle mass.28 Heat patches and warming creams relieve pain by dilating blood vessels and increasing blood flow to the area, which also promotes healing. Ice packs relieve pain and reduce swelling from an injury, but they won’t reduce muscle damage, as many sports enthusiasts believe.29
  • 21. Juvenile arthritis affects 12,000 children under the age of 16 and can strike in infancy. It is thought that a combination of genetic factors and environmental triggers, which have not yet been identified, are to blame.30 Osteoarthritis, the most common form of the condition, is caused by wear and tear. More than six million people in the UK have osteoarthritis in one or both knees and more than 650,000 have it in one or both hips.34 Knee problems are set to soar as a result of the obesity epidemic. One study estimates that every kilogram increase in body weight raises the risk of osteoarthritis of the knee by between nine and 13 per cent.31 Profanities increase your pain threshold. A study at Keele University found that volunteers could hold their hand in cold water for twice as long when they swore. But swearing all the time dilutes the effect.35 Ligaments connect bone to bone and stabilize joints such as the knee, while tendons link muscle to bone and facilitate movement. Quinine, the ingredient that gives tonic water its bitter taste, is used as a last resort treatment for night time leg cramps.36 Musculoskeletal conditions are estimated to cost the UK £5.7billion a year and around 10 million lost working days.32 NSAIDs or non-steroidal anti-inflammatory drugs, are commonly taken to relieve aches and pains but can cause gastric irritation and, in high doses, can increase the risk of a heart attack.33 Rheumatoid arthritis is an autoimmune condition which can strike at any age and affects three times more women than men. Around 400,000 adults in the UK have been diagnosed with the condition.37 Sciatica is pain caused by any compression or irritation of the sciatic nerve, which runs from the pelvis, through the buttocks to the feet. The most common form is a slipped disc. 19
  • 22. TENs (transcutaneous electrical nerve stimulation) provide an effective treatment for pain and muscle spasm. They deliver bursts of low voltage electricity which helps block pain signals to the brain. Ultrasound is commonly used to treat tendon and ligament injuries and studies suggest it improves mobility and reduces pain slightly in patients with osteoarthritis.38 It can also be used to monitor the effectiveness of treatments for rheumatoid arthritis.39 Vitamin D deficiency can cause bone pain and tenderness. Sunshine is the best source, but lack of light and the angle of the sun mean most of us have low levels during winter. Anyone living above 52º north, the same latitude as Birmingham, cannot make enough from the action of sun on their skin from October to March.40 20 Walking is an ideal form of exercise for anyone with joint pain and has been shown to reduce the pain of arthritis by a third.41 X-ray evidence suggests that around 8.5 million people in the UK have osteoarthritis of the spine.42 Yoga provides effective pain relief for people with lower back pain and both osteo and rheumatoid arthritis. It also improves mobility and reduces curvature of the spine.43 Zinc is found in abundance in both the spinal cord and brain and numerous studies have shown it acts as a painkiller.44 There is also evidence that people with fibromyalgia, a syndrome characterised by widespread pain, are low in zinc.
  • 23. Stats and facts references: 21 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx 22 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx 23 http://www.backcare.org.uk/factsandfigures 24 L Guéguen et al. the Bioavailability of Dietary Calcium. J Am Coll Nutr April 2000 vol. 19no. suppl 2 119S-136S http://www.jacn.org/content/19/suppl_2/119S.full 25 Arthritis Hurts — the Emotional Impact of Arthritis Pain http://www.arthritiscare.org.uk/Search/search_results_page_view?SearchableText=depression 26 Jaan Kangilaski β-Endorphin levels lower in arthritis patients JAMA. 1981;246(3):203. doi:10.1001/jama.1981.03320030005004. 27 http://jama.jamanetwork.com/article.aspx?articleid=359545 28 http://www.nhs.uk/Conditions/Fibromyalgia/Pages/Introduction.aspx 29 http://www.ncbi.nlm.nih.gov/pubmed/23247327 30 http://www.reuters.com/article/2013/06/21/us-health-rapid-cooling-strained-muscle-idUSBRE95K13W20130621 31 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725004/pdf/v039p00004.pdf 32 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx 33 http://www.nhs.uk/news/2013/05May/Pages/high-dose-nsaid-painkiller-heart-risk-small-significant.aspx 34 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx 35 http://www.ncbi.nlm.nih.gov/pubmed/22078790 36 http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON085085 37 http://www.nras.org.uk/about_rheumatoid_arthritis/what_is_ra/what_is_ra.aspx 38 http://summaries.cochrane.org/CD003132/therapeutic-ultrasound-for-osteoarthritis 39 http://www.nras.org.uk/about_rheumatoid_arthritis/established_disease/managing_well/ultrasound_can_it_help_me.aspx 40 Web A et al. Influence of season and latitude on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin. J Clin Endocrinol Metab.1988;67:373-8 http://www.ncbi.nlm.nih. gov/pubmed/2839537 41 Ann Intern Med. 1992 Apr 1;116(7):529-34. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized, controlled trial. Kovar PA, Allegrante JP, MacKenzie CR, Peterson MG, Gutin B, Charlson ME. 42 Arthritis Research UK Key Facts http://www.arthritisresearchuk.org/arthritis-information/data-and-statistics.aspx 43 Musculoskeletal Care 2013 Jan 9. doi: 10.1002/msc.1042. http://www.ncbi.nlm.nih.gov/pubmed/23300142 44 http://www.nature.com/neuro/journal/v14/n8/full/nn.2844.html http://www.painresearchforum.org/news/7930-zinc-acts-nmda-receptors-relieve-pain 45 http://www.technicaljournalsonline.com/ijeat/VOL%20III/IJAET%20VOL%20III%20ISSUE%20II%20APRIL%20JUNE%202012/25%20IJAET%20Vol%20III%20Issue%20II%202012.pdf 21