Given the ageing world population, musculoskeletal disorders are becoming increasingly important. These disorders are now the third most common problem managed by general practitioners in Australia,² making up 11.6% of cases in comparison to skin disorders (11.6%) and respiratory diseases (16.5%). Osteoarthritis is already a major cause of disability in Australia,³ and musculoskeletal trauma is becoming a serious problem in developing countries.¹

This Supplement focuses on the pivotal role of the general practitioner in managing chronic musculoskeletal disease, and on osteoarthritis because of its prevalence and importance in the ageing population.

The relationship between osteoarthritis of the weight-bearing joints (particularly the knee) and obesity is now well accepted. Weight loss will reduce pain and speed rehabilitation in patients with knee osteoarthritis. Exercise and other physical therapies represent the first line of treatment for osteoarthritis,^4,5 supplemented when necessary by pain relieving agents. There is evidence that patients prefer anti-inflammatory drugs over pure analgesic agents in relieving pain in osteoarthritis.⁶ COX-2 inhibitors, available for the first time in the 1990s, have efficacy equivalent to that of non-selective, non-steroidal anti-inflammatory drugs (NSAIDs) but a much better safety profile (particularly for gastrointestinal complications).^7,8 Another promising development is the recent report that suggests that glucosamine sulfate retards the progression of symptomatic knee osteoarthritis.⁹ This is the first report of a disease-modifying therapy for osteoarthritis. Finally, if all else fails, total joint replacements are now among the most cost-effective interventions in medicine¹⁰ and significantly improve the quality of life in patients with osteoarthritis or rheumatoid arthritis.

Rheumatoid arthritis is still a major cause of long term disability and there is increasing evidence that early diagnosis and aggressive treatment with disease-modifying antirheumatic drugs lead to more rapid disease suppression, although this may not result in better remission rates.¹¹ Over the last decade our understanding of the inflammatory process in rheumatoid arthritis has improved significantly, with the delineation of many of the cytokine and other mediator pathways.¹² A range of new drugs, particularly the monoclonal antibodies,¹³ can significantly improve outcomes (at least in the short term), with agents directed against tumour necrosis factor¹⁴ and interleukin-1 receptor antagonist.¹⁵ Other new agents, such as leflunomide,¹⁶ have also been shown to slow progression of rheumatoid arthritis.

Biological therapies will doubtless make a significant difference to the management of rheumatoid arthritis, but even transplantation and aggressive chemotherapy do not seem to cure the disease.¹⁷

As we move into the Bone and Joint Decade and start to tackle the difficult therapeutic and research issues relating to low back pain¹⁸ or occupational pain and injury, we need to focus very much on education.¹⁹ This educational agenda will involve the training of undergraduates, graduates and, most importantly, postgraduates across a broad range of health professions.

The Bone and Joint Decade focuses on five groups of conditions: osteoarthritis; osteoporosis; musculoskeletal trauma; inflammatory arthritis; and back pain. All of these conditions are common and chronic and will be treated by a multiprofessional team with significant input from general practitioners. This Supplement focuses on the major advances in management of arthritis that have occurred in recent years and shows that in 2001 something positive can be done for patients with musculoskeletal disease.

Peter M Brooks
Executive Dean, Health Sciences
The University of Queensland

1. Brooks PM, Hart JAL. The Bone and Joint Decade 2000-2010. Med J Aust 2000; 172: 307-308.
2. Britt H, Miller GC, Charles J, Knox S, et al. General practice activity in Australia 1999-2000. Canberra: Australian Institute of Health and Welfare, 2000 (AIHW Cat. No. GEP-5).
3. Mathers CD, Vos T, Stevenson CE, et al. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000 172: 592-596.
4. Fransen M, Crosbie J, Edmonds J. Physical therapy is effective for patients with osteoarthritis of the knee: a randomised controlled clinical trial. J Rheumatol 2001; 28: 156-164.
5. March LM, Stenmark J. Non-pharmacological approaches to managing arthritis. Med J Aust 2001; 175 Suppl 3: S102-S107.
6. Wolfe F, Zhao S, Lane N. Preference for nonsteroidal anti-inflammatory drugs over acetaminophen by rheumatic disease patients. Arthritis Rheum 2000; 43: 378-385.
7. Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs non-steroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis; the class study: a randomised controlled trial. Celecoxib longterm arthritis safety study. JAMA 2000; 284: 1247-1255.
8. Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343: 1520-1528.
9. Reginster JY, Deroisy R, Rovati LC, et al. Long term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial. Lancet 2001; 357: 251-256.
10. Liang MH, Cullen KE, Larson MG, et al. Cost effectiveness of total joint arthroplasty in osteoarthritis. Arthritis Rheum 1986; 29: 937-943.
11. Proudman SM, Conaghan PG, Richardson C, et al. Treatment of poor prognosis early rheumatoid arthritis. Arthritis Rheum 2000; 43: 1809-1819.
12. Choy EHS, Panayi GS. Cytokine pathways and joint inflammation in rheumatoid arthritis. N Engl J Med 2001; 344: 907-916.
13. Breedveld FC. Therapeutic monoclonal antibodies. Lancet 2000; 355: 735-740.
14. Bathon JM, Martin RW, Fleischmann RM, et al. A comparison of etanercept and methotrexate in patients with early rheumatoid arthritis. N Engl J Med 2000; 343: 1586-1593.
15. Cunnane G, Madigan A, Murphy E, et al. The effects of treatment with interleukin-1 receptor antagonist on the inflamed synovial membrane in rheumatoid arthritis. Rheumatology 2001; 40: 62-69.
16. Sharp JT, Strand V, Leung H et al. Treatment with leflunomide slows radiographic progression of rheumatoid arthritis. Arthritis Rheum 2000; 43: 495-505.
17. Snowden J, Brooks PM, Biggs JC. Haemopoietic stem cell transplantation for autoimmune disease. Br J Haematol 1997; 99: 9-22.
18. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344: 303-370.
19. Dequeker J, Rasker JJ, El Hadidi T. Globalisation of rheumatology: activities of ILAR, think global not local. J Rheumatol 2001; 28: 227-231.

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