The burden of musculoskeletal disorders in the countries of the Eastern Mediterranean region of the World Health Organization (EMRO): Study period 2000-2017

Background: MSK health is imperative for the active participation of an individual in society and MSK related disorders more direly affects a person's quality of life compared other non-communicable disease while it also negatively effects the health system and economy of a country. The current manuscript analyzed and describes the disease burden of MSK disorders in the EMRO region. Methods: This was a cross-sectional descriptive-analytical study conducted based on data published by the Global Burden of Disease Database for MSK disorders up to 2017. The study target comprised population from all countries of the EMRO region of World Health Organization. The present study considered, MSK disorders such as (rheumatoid arthritis), (osteoarthritis), (Low back pain), (neck pain), (gout) and (other Musculoskeletal disorders. The DALY index was used to measure total disease burden. Results: MSK disorders in the world and in the EMRO region was ranked 5th (4% of total disease burden) and 7th (5% of total disease burden) among all diseases in 2017, respectively. Women over 30 years of age in the EMRO region had the highest risk of MSK disorders compared to other regions and in addition, the DALY lost in EMRO region due to MSK disorders was higher in women of all age categories than men. According to the results of this study, Low back pain, Other musculoskeletal disorders and Neck pain had the highest prevalence and burden of disease in the EMRO region and the world. Bahrain, Iran, and Morocco had the highest incidence of MSK DALY score in the EMRO region, and Somalia, Djibouti, and Afghanistan had the lowest incidence of MSK disorders and DALY score, respectively. Conclusion: With the increase in geriatric population and obesity especially in developing countries, consequently, more people tend to suffer from MSK disorders and it is predicted that this spike will continue in the coming decades. Taking in to account the high prevalence and burden of MSK disorders, forces government and health-policy makers to focus more on preventive cares and rehabilitation. study population of includes all countries of the Eastern Mediterranean region of the World Health Organization (EMRO) based on information on their disease burden during the period of 2000-2017. The present study, evaluates MSK disorders such as rheumatoid arthritis, osteoarthritis, low back pain, neck pain, gout and other musculoskeletal disorders. Our study uses DALY index to measure total disease burden. DALY is formulated by the sum of years of potential life lost due to premature death (YLL) and the years of productive life lost due to disability (YLD) expressed as follows:


Background
Musculoskeletal health plays a pivotal role in de ning a person's overall productivity such as his capabilities, functionalities and all other aspects of life that involves active participation. MSK related disorders and disease have a more profound effect in reducing the quality of life compared to other non-communicable disease (1). Unfortunately, it leads to an early retirement, reduced income and nancial instability in patients (2). A high disease burden of MSK disorders can be witnessed in developing and less developing countries can be related with the increasing geriatric population of these countries (3,4) This issue is predicted to have a magni ed effect in the upcoming decades because many developing countries tend to ignore its impact in the present time as they are busy allocating their limited resources in other more competitive elds of research (5).
Moreover, we see an unequal distribution of access to these services and facilities stemming from political instability, war, low income and unemployment existing in those countries. According to the National Institute of Occupational Safety and Health, MSK is a disorder that affects the system of human body, especially the bones, spinal discs, tendons, joints, ligaments, cartilage, nerves including blood vessels (6) of which about more than 150 types have been diagnosed that could cause pain and result in impaired function and in the long run may deprive the person of the ability of doing daily basic functions which in turn could signi cantly deteriorate mental health and accelerate the progression of other chronic disease as well and add to mortality rates (2,7). According to the study based on MSK disease burden between the years 1990 and 2010, the DALYs index of MSK disorders increased by 4.7 percent and its share of contribution to the total disease burden reached 6.8 percent in 2010. Statistics show that the prevalence of MSK has not yet reached its peak and continues to increase owing to the increase in average life expectancy. If this upward trend continues, governments should be prepared to spend quite a great deal on their health care systems (8) Studies also show that musculoskeletal disease includes three of the top 10 indexes in terms of disease burden and disability (9). Muscular skeletal disorders of the muscles is recognized as a growing problem in health care and the second leading cause of disability after mental disorders (8).The report from WHO states that about 10 to 50 percent of the world's population suffer from these disorders (10) and about one in every two American is affected by MSK disorders(2). Given the high prevalence and nancial burden in icted by MSK disorders, governments are deemed to emphasize more on preventive care and rehabilitation (11).
Damian Hoy et al, in their study in 2014 showed that among the 291 diseases studied, back pain had the highest rank in terms of disability index (YLDs) and was ranked sixth in terms of overall disease burden index (DALYs) (4). Another study that evaluated the morbidity of neck pain showed that among the 291 cases reported by the Global Disease Burden in 2010, neck pain based on criteria of years of life lived with disability (YLDs) and (DALYs), had been ranked fourth and twenty one respectively (12).Undoubtedly, MSK disorders impose a heavy nancial burden on individuals, health care systems and governments (8). Many studies have depicted the different ways in which MSK disorders negatively impacted the economy, as in by raising costs for governments, as well as lowering income due to deterred e ciency and productivity, early retirement, and absenteeism at work (6,13,14) In 2014, 8.3 million working days were wasted in the UK as consequence of MSK disorders, and it was stated that in the EU, more than 40 million workers suffered MSK injuries, which is equivalent to one-seventh of the population (6). Between 1992 and 2010, it was estimated, about 29 to 35 percent of worker absenteeism in U.S as a result of occupational injuries in private factories accounted to MSK disorders (6) The annual economic burden of these disorders in the United States is estimated to be between $ 45 billion and $ 54 billion (14). The economic burden in icted by these disorders on low-income or middle-income countries due to negligence is more conspicuous than in high-income countries (15).
Data on funding and budget size for various diseases in the United States indicate that MSK disorders have been assigned the least amount of budget via the National Institutes of Health Research compared to other diseases like cardiovascular disease and cancer (16). The negligence of these disorders can be attributed to its insigni cant role in leading to direct mortality and also due to its irreversible nature. In addition, in some cases, MSK is considered to be part of the natural aging process in the population (15). Precise planning and management can signi cantly reduce the rate of these disorders and minimize the additional and secondary costs imposed by it (7) In fact, a multidisciplinary approach is imperative to prevent, treat, and address this problem, by means of raising public awareness of risk factors, and in order to assure success , it is necessary to encourage lifestyle changes , welcome more patients .and it is and further improvise this approach with the help of the scienti c and medical community (16). Musculoskeletal disorders have not been given much attention, despite its importance in public health, especially in low-and middle-income countries. The epidemiological data from Eastern Mediterranean region (EMR), on musculoskeletal disorders are scattered and disorganized and are not to compare. Most of the existing data in this region come from basic surveys of the community-based program to control rheumatic diseases (15). Many Mediterranean countries, including Egypt, Iran, Kuwait, Lebanon, Pakistan and Tunisia, have introduced communitybased programs to control rheumatic diseases over the past two decades. According to a 2017 study by Moradi et al.on the disease burden of MSK disorders in the Mediterranean region between 1990 and 2013, neck pain and low back pain were the top most disorders reported, for example in Iran the prevalence of neck pain and back pain were 23.7% and 14.2%, respectively, and in Kuwait the prevalence of back pain in male and female students was reported to be 20.6% and 39.3%, respectively. Thus, extensive research is deemed as the need of the hour to evaluate the most effective and cost-effective strategy for preventing and managing MSK.

Methods
The present study is a cross-sectional, descriptive-analytical study based on the latest available data from the Global Burden Disease (GBD) database (2017) on MSK disorders. We extracted this secondary data from Global Burden Disease (GBD) database site(http://www.healthdata.org/) and performed the necessary statistical analysis on it. The study population of includes all countries of the Eastern Mediterranean region of the World Health Organization (EMRO) based on information on their disease burden during the period of 2000-2017. The present study, evaluates MSK disorders such as rheumatoid arthritis, osteoarthritis, low back pain, neck pain, gout and other musculoskeletal disorders. Our study uses DALY index to measure total disease burden. DALY is formulated by the sum of years of potential life lost due to premature death (YLL) and the years of productive life lost due to disability (YLD) expressed as follows: Considering the factors of r, k and β changes equation (2) to equation (3) The Disability-Adjusted Life Years (DALY) index is acts as the main criteria to measure total disease burden. Accordingly, the DALY level registered in the database of GBD separately on MSK disorders (rheumatoid arthritis, osteoarthritis, back pain, neck pain, gout and other disorders of skeletal muscle) for men and women in different age groups (16 different age groups) for countries in the EMRO zone that consists Qatar, Saudi Arabia, Syria, Tunisia, Yemen, United Arab Emirates, Iran, Bahrain, Afghanistan, Egypt, Somalia, Jordan, Libya, Iraq, Kuwait, Sudan, Lebanon, Morocco, Palestine, Oman, Djibout was extracted per year for the period between 2000-2017 and were analyzed with the aid of MS EXCEL software and reported with the use of descriptive statistics. The information entered in the GBD database is based on data obtained from research evidence estimated by the countries concerned and some poor may not be recorded in some poor countries that did not have recorded data due to economic and health development. were excluded from the study.
In all age groups in EMRO region DALY lost as a result of MSK disorders was higher in the population of women than men. The results also show that the difference in the DALY index between men and women above 10 years of age increased linearly as they got older till the age of 60 and from 60 to 74 the difference in index remained constant but after 74 years onwards the difference of index in the DALY of these two groups decreased ( Figure 5).
Out of 6 types of MSK disorders, Low back pain, Neck pain, other musculoskeletal disorders and Osteoarthritis in all age groups in the EMRO region had the highest score. Low back pain also appears to be prevalent in all age groups above 10 years. MSK disorders of all sorts were low in the younger age categories but increased gradually with increase in age. Age groups between 65-79 had the highest DALY value for lower back pain disorder. Furthermore, the age category of 70-74 had highest DALY index for neck pain and other musculoskeletal disorders. (Figure 6).
In EMRO region, the burden of MSK disorders in 2000 and 2017, was reported to be 1383 and 1596 DALY per 100,000 cases respectively. Meanwhile, the global DALY index was 1635 and 1816 per 100,000 people, respectively. The growth rate of MSK disease burden during the period 2000-2017 in the EMRO region and the world was 15% and 11%, respectively. In 2017, these disorders accounted for 6% of the total global disease and was ranked 5th while these disorders contributed for 6.2% of disease burden in EMRO region alone and ranked 7th. The prevalence status for MSK disorders was higher in women compared to men both globally and in the EMRO region during the year 2000 and 2017. Low back pain, other musculoskeletal disorders and neck pain were reported to be the most common disorders among men and women in the EMRO region and the world. The prevalence rate for all 6 types of MSK disorders except gout was higher in women than men throughout different years in EMRO region and the world. Moreover, based on results of the year 2000, the prevalence of MSK disorders in EMRO region (29874 cases per 100,000) was less that of the world (35962 cases per 100,000 people). In 2017, the prevalence of these disorders increased in both globally and in EMRO zone, but the global prevalence (41023 cases per 100,000 people) was still higher than the EMRO region (35034 cases per 100,000 people). The incidence of musculoskeletal disorders consistently increased globally and in the EMRO region, with the highest incidence being related to low back pain and neck pain disorders (Table 2).  (Figure 7).

Discussion
MSK disorders contribute to highest proportion as the cause for persistent pain in different regions and geographies (17). Pain and disability associated with MSK disorders have a signi cant impact on individuals, their families, community and health and economic systems (18) to the extent in comparison to other non-communicable diseases, it results in the loss of many precious years of active labor in life (19) and adds to large global burden (9). Economic consequences that follows include rise in health care costs and insurance, reduced labor productivity, work absenteeism. Therefore, considering the importance of this issue, the burden of MSK disorders in the Eastern Mediterranean countries (EMRO) during the period 2000 to 2017 was evaluated using the data from existing studies in the eld of total disease burden (GBD). As was stated by the results of this study, the growth rate of MSK disorders during the period 2000-2017 in the EMRO region and the world was 15% and 11%, respectively. The study ndings of Al Hey et mentioned an increase of 61.6% in MSK disorders during the years between 1990 and 2016 followed by an increase of 19.6% during the period between 2006 and 2016(20). In 2017, overall only 6% of MSK disorders contributed to the total global disease burden, ranked 5th; whereas they accounted for 6.2% of the, total disease burden in the EMRO region alone (ranked seventh). The prevalence of this disease is predicted to continue to spike with the increased pattern of sedentary lifestyle, obesity and ageing (21 Findings present a surge in difference of prevalence between men and women in EMRO region and in the world and in all age groups, DALY lost to MSK disorders had a higher prevalence rate in women than men. The age group of 70-74 years had the highest DALY score for MSK in EMRO region. Among women in the six WHO areas, the EMRO had the highest incidence of MSK in all age groups over 30 years. The age category above 30 in the EMRO region had the highest DALY score due to MSK disorders. Numerous studies so far, have pointed out the surge in disease burden for MSK disorders with increasing age. (3,24). The female population have higher burden of MSD compared to the males. Also, the difference in DALY index between men and women above 10 years of age increased sequentially with increasing age up to 60 years and from 60 to 74 this difference remained constant but after 74 years of age the difference between the DALY index of these two groups signi cantly decreased. Likewise, the study by Cross et al, in the year 2014, indicated that the standardized prevalence based on age was higher in women than men and prevalence increased steadily with age (25).
The study led by Hoy at el study in 2014 showed that low back pain was higher in men than women, and in this study, the age group of 65 to 79 years had the highest DALY for low back pain (9).
Out of the 6 types of MSK disorders, Low back pain, Neck pain had the highest DALY in all age groups in the EMRO region and all 6 types of MSK disorders with the exception of Gout was found to be more prevalent in women than men in all age groups both, in EMRO region and the globally. were not war-zoned at the time of study, and it should be brought to attention that the researches evaluating MSK disorders in countries like Iran has been carried out on large scale unlike other countries of the EMRO zone, adding more evidence to the database which possibly explains the higher incidence of MSK disorders in Iran.
The prevalence of MSK disorders has been given much emphasis in developing countries owing to increase in obesity and early ageing of population(29) MSK disorders imposes heavy diagnostic-therapeutic costs for the individual, the health system, and the community, and the most direct costs being related to physiotherapy, inpatient services, pharmacy, and primary care (30).Hence, preventive measures for these disorders signi cantly could reduce the disease burden and costs imposed on the individual and society. Therefore, it is recommended to perform extensive practical researches in the eld of health maintenance and prevention measures for MSK disorders in order to encourage a healthy lifestyle with the aim of reducing obesity and increase physical activity and make the data accessible for policy-makers.

Conclusion
It is well known that MSK disorders at present, account for a large proportion of disability in the world. More people will suffer from MSK as the population grows and with increase in obesity, and it is expected to keep spiking over the coming decades. The current trend for MSK disease burden, especially in developing countries, is clearly high, and given the high prevalence and high burden of, obviously government programs and health policy makers should pay more heed on preventive care and rehabilitation (11) especially since low-income countries are direly affected and since MSK disorders tend to be more prevalent in middle and low income countries(20). On one hand, the growth of the elderly population in countries around the world, especially developing countries such as Iran, aging in the near future, and on the other hand, to achieve sustainable development goals and promote a ful lling healthy decade of 2020-2030 for the elderly, innovative and continuous efforts must be made on improving MSK health.