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

2 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 Foreword: What works for an age old problem?

Every year in the UK 20% of the population present with A poll of 1,000 people who suffer aches and pains a new onset or recurrence of a musculoskeletal problem.1 commissioned by the Simplyhealth Advisory Research Panel In fact, musculoskeletal disorders (MSDs) are the most (ShARP), found that more than a third (35%) take to their common work related problem in Europe2, the most beds in the hope it will ease their pain. Exercise, such as common cause of physical disability3 and the biggest reason yoga7 and workouts guided by a physiotherapist,8 is proven to for long term treatment.4 Musculoskeletal disorders can improve spinal aches and pains, but only 6% of sufferers use affect the body’s muscles, ligaments, tendons, nerves and it to relieve their symptoms and almost half (42%) say pain joints, and most commonly result in back pain, knee pain, prevents them from exercising as much as they would like. neck and shoulder pain, hip and limb pain. Team GB kayaker, sports scientist and physiotherapist, Paul A recent study5 into how we manage our musculoskeletal Hobrough from ShARP notes: “There is a real danger that health reveals that two out of five Britons believe that by people can become trapped in a vicious cycle with lack of resting, their musculoskeletal condition will improve, what exercise leading to increased stiffness, pain and muscle they don’t realise is that it could in fact be making it worse. wastage and therefore less support for the spine and an Studies have shown that rest intensifies and prolongs back increased risk of problems. pain, reduces mobility and extends recovery time.6

2 1 Clarke A & Symmons D. The burden of rheumatic disease. Medicine 2006; 34 (9): 333-335 2 European Agency for Safety and Health at Work 3 Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003;81:646-56. 4 European Opinion Research Group EEIG. Health, Food and Alcohol and Safety. Special Eurobarometer 186. European Commission, 2003 5 One Poll survey of 1,000 people carried out in June 2013 “On top of that, reduced activity increases the likelihood of Pain hot spots weight gain which places even more stress on our joints. The ShARP study identified the lower back as the nation’s The evidence is clear; those suffering from chronic low number one sore spot, with seven out of ten (70%) back pain benefit from exercise and often get worse with respondents reporting problems in this region. prolonged periods of inactivity.” But worryingly, three out of four sufferers do not ask for Being overweight is a key contributor to a lot of muscle and professional advice on musculoskeletal problems, with more joint pain, affecting many of the weight-bearing joints. One than a third (36%) of those who do not seek help saying long term study found that obesity increases the risk of the cost of care puts them off. Another major barrier is the 9 osteoarthritis of the knee by a factor of four. mistaken belief that a doctor’s referral is needed to see a Given the global epidemic of obesity it is perhaps not physiotherapist.11 surprising that the incidence of arthritis of the knee climbed The following report, brought to you by ShARP, explores 10 by 22% from 1990 to 2005 and continues to rise. the area of back pain and general muscle, bone and joint A weighty link problems. It looks at who suffers and why; the impact of our body shape, weight and height and how age too, as well The new study by ShARP has also revealed a link between as suffering in silence, can make our musculoskeletal health weight and back pain, with almost all (99.5%) of those worse. The report also suggests how we can treat muscle, weighing 14 stone or more reporting problems. bone and joint problems quickly and conveniently.

3 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 Section 1: Fairer sex face an unfair burden

Women experience more acute back pain than men, 25% Painkillers are preferred by women, with: compared to 20%, and are more prone to knee problems, ✔ over half (57%) taking them to relieve back pain, with one in three (33%) reporting pain in these joints compared to fewer than half (43%) of men — which compared to one in five men (22%). is just as well as there is evidence that long term use Women tend to turn to physical treatments such as of prescription painkillers increases the risk of erectile physiotherapy, chiropractic and massage, with more than dysfunction.12 half (54%) of those questioned for the Simplyhealth Advisory Research Panel survey reporting they use one of these Peak pain times approaches to relieve back pain, compared to just over a Pain and stiffness peak at the start and at the end of the third (39%) of men. day for both sexes, but the pattern is more pronounced in women: However, women are also most likely to risk exacerbating their back pain problems by resting, 38% take to their beds ✔ 18% of women reported problems in the morning, compared to 30% of males. compared to 12% of men ✔ Men are three times more likely to do nothing to help their 16% of respondents said they suffer more in the evening, back pain and simply hope their pain goes away, 12% put compared to 10% of men. their heads in the sand and suffer compared to just 4% of Both sexes try to soldier on and manage chores around the the women surveyed. house and garden on their own, but men are the most likely to employ someone to help out — 16% compared to 10%.

4 12 http://www.eurekalert.org/pub_releases/2013-05/kp-luo051013.php 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 Section 2: Time takes a toll

Back pain becomes more common as we age, with the Asking for help ShARP study revealing that 99% of over 50s with joint Over 55s are most willing to ask their GP for help, with a problems reporting they get it in the back. Pain and stiffness third (33%) visiting their doctor for advice, compared to a doubles with age, with more than one in three (36%) of quarter of those under the age of 40. those aged over 55 reporting daily discomfort compared to just 15% of those aged 25 to 30. The benefits of physiotherapy are most often recognised by under 40s, with almost one in five (19%) turning to a Neck and shoulder problems peak earlier. Two out of five physiotherapist for treatment, compared to 15% of over 40s. under 35 year olds suffer neck pain and almost a third (30%) report shoulder problems, while for the over 55s the Painkillers are most commonly used by over 50s, with figures were just 17% and 30%. The increased time younger two out of three (63%) resorting to them for back pain respondents spend staring at screens is probably a factor — despite the known risks of long term use of non steroidal 13 behind neck and shoulder pain. anti-inflammatory drugs (NSAIDs) such as aspirin.

The growth in technology and working hours has had a big Oral NSAIDs are associated with a slightly elevated risk impact on the younger generation. Around half of under of heart attack or stroke and they are not recommended 30s sit at a computer for more than six hours a day (51%), for anyone with a history of cardiac problems, high blood play games on a console or mobile device (50%) or watch pressure or diabetes — which are all more common in this two hours of more television a day (47%), compared to an age group. average across all ages of 40%, 30% and 40% respectively.

6 13 http://bestpractice.bmj.com/best-practice/monograph/337.html Dr Gill Jenkins, GP and expert from ShARP, notes: “Over- the-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 Section 3: Body of evidence

Our build shapes our experience of joint and muscle pain ✔ obesity was associated with higher rates of daily and the ShARP study adds to the growing body of evidence discomfort, which was reported by almost half (47%) of that obesity is a major contributor to the rising rates of back those in the heaviest group, compared to just 15% of and knee pain. those in the lightest

The latest meta-analysis, a type of super study which ✔ more than a third (33%) of those weighing 14 stone or examines all the relevant published evidence, has shown a more reported knee pain — almost twice the number clear association between being overweight or obese and (19%) who were 9.5 stone or less 14 an increased incidence of lower back pain, and obesity Obesity and joint pain is a bad combination, as pain often has been identified as the single most common cause of limits physical activity, which increases weight gain and puts 15 preventable osteoarthritis of the knee. even more pressure on already painful joints. The ShARP Comparable trends emerged from the survey: survey confirmed this cycle may already be a reality for many Britons. An additional risk factor is that around half (48%) of ✔ more than four out of five (86%) of those weighing more those weighing 14 stone or more rest to relieve their pain, than 14 stone reported problems with lower back pain compared to an average of around a third (35%) who weigh ✔ almost all (92%) those weighing in excess of 17 stone less. admitted it was an issue

8 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 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 Section 4: As stiff as a board

While our backs are the number one pain and problem gripe, Age and weight too has a part to play when it comes to stiffness, and muscular aches and pains are also a big issue musculoskeletal pain. The ShARP survey revealed that: too and it is no wonder so many of us feel that our bodies are ✔ those that are aged 45 or more tend to suffer daily just one giant knot. ✔ respondents who weighed over 14 stone were much more ✔ 22% of the ShARP study’s respondents suffer from likely to suffer daily pain, while generally those who were stiffness, aches and pains daily under nine stone had intermittent pain ✔ 14% suffer from stiffness or aches and pains weekly Pain that stops play ✔ 10% suffered from stiffness or aches and pains at least once a month Musculoskeletal body pain also seems to prevent sufferers from getting on with an active life, from causing havoc with exercise While some of us suffer daily, weekly or monthly from stiffness plans, impacting on general lifestyles, to not being able to wear or aches and pains, exercise (for 14%), gardening (13%) high heels any more. Stats and facts reveal that: and sleeping awkwardly (13%) cause muscular problems for those of us that are not common sufferers of musculoskeletal ✔ 32% of sufferers complained they could not do as much problems. 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 ✔ 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 Blame factors Other blame culprits Twenty-three per cent of those suffering from musculoskeletal ✔ just over one third (34%) thought that musculoskeletal issues blame their work environment where they remain in the pain was an inevitable part of ageing same position for lengthy periods and 16% claim the chair they ✔ diet and genetic factors were considered to have an had at work was a factor. influence by 30% and 22% respectively on muscle, bone And while most of us associate exercise as being good for our and joint pain health, when it comes to musculoskeletal pain the opposite Suffering in silence was thought to be true as 20% blamed weight bearing exercise for causing musculoskeletal problems, so they tended to Many of us it seems suffer from poor musculoskeletal health avoid it. Again greater education is needed on the care for and over 50% of us admit to doing nothing to help our musculoskeletal health as weight bearing exercises have been musculoskeletal health on a day-to-day basis. This is despite shown in research as being very good for joint health. 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 Section 5: Simply the best approach

It is unlikely that we can completely avoid aches and pains, “Vitamin D is essential to prevent rickets in childhood, but but we do have the power to reduce their impact on daily life. it is less well known that deficiency — which is common during UK winters — is associated with bone pain in adults. Physiotherapist Paul Hobrough says: “Prevention, timely And new evidence is emerging all the time about the role of treatment and on going advice from a health professional can other nutrients including protein, folate and vitamin B12 in all make a real difference in terms of heading off problems and maintaining musculoskeletal health.” taking control when an issue arises. Ensuring the sufferer gets high quality advice from a recognised health professional as Don’t suffer in silence early as possible is the key to reducing long term suffering and There is clear evidence that when pain strikes, prompt action costly absence from the workforce. and professional advice can speed recovery and reduce the “Watching our weight and getting plenty of exercise are risk of long term dependence on painkillers. both essential for optimum musculoskeletal health, but there But sadly, this study reveals that thousands of Britons with is increasing evidence that good nutrition is also a major back pain and other aches and pains are not accessing the weapon against the ravages of age related wear and tear.” care that could make a difference. Dr Gill Jenkins explains: “We have known for a long time Many admit they are concerned about the cost of treatment. that calcium is incredibly important for healthy bones and With a health cash plan from Simplyhealth you can claim the better our intake in childhood and the teenage years, the back the cost of visiting a physiotherapist, chiropractor or better our lifetime bone density. osteopath* and focus on getting the right treatment without being worried about how much it will cost. 13 *Up to annual limits The company, which was founded 140 years ago has a A report by the British Pain Society and Help the Aged found: philosophy which is as straightforward as its name: “Older people are more at risk of pain than other sections of the population, but less likely than younger people to “In a world where so many people can’t be bothered, we’re experience good pain management.” proud to be the ones that can. Some experts are also concerned about the negative “We believe in helping people access affordable healthcare impact of ongoing changes to the National Health Service and delivering exceptional personal customer service.” and a recent Health Select Committee report warned: “The As a result of that commitment, it now boasts more than four reorganisation process continues to complicate the push for million customers and eight out of ten would recommend efficiency gains. Although it may have facilitated savings in Simplyhealth to family and friends. some cases, we heard that it more often creates disruption and distraction.”18 Last word… Aches and pains associated with our body’s skeleton and As a result, in this period of change and confusion, it is more muscles are a fact of life for hundreds of thousands of people important than ever for people with musculoskeletal problems living in the UK and back pain alone will affect four out of to take control of their own health. five of us at some time in our lives.16 Problems get worse as It is becoming increasingly evident that the NHS may no we age, with around five million people over the age of 65 longer be able to support all of our healthcare needs and suffering some degree of discomfort.17 some local services are already being reduced. Pain control and physiotherapy — our most effective weapons against

14 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 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. So for those people who do not enjoy the best of ‘skeleton and muscular health’ seek There are many affordable options today allowing greater advice and help now, don’t suffer in silence. access to medical specialists, all of which can help sufferers deal with issues fast and in many cases resolve the problem. ShARP 15 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 About Simplyhealth

We’ve been helping people access affordable healthcare We became Simplyhealth in 2009 after bringing together for 140 years. Our range of health cash plans, dental plans, BCWA, HealthSure, HSA, LHF and Totally Active. In 2011 private medical insurance and self funded health plans help we acquired Denplan, the UK’s leading dental payment plan individuals, families and businesses. We are committed to specialist. Denplan will continue to operate as a standalone providing excellent personal customer service and doing the business. right thing for our customers. We recently won the Customer Simplyhealth Independent Living helps people get the most Commitment Award at the UK Customer Satisfaction out of life through mobility products and daily living aids. Awards, organised by the Institute of Customer Service. We have specialist Independent Living centres in Andover, Our health cash plans and dental plans help people claim Bristol, Manchester and Leeds, plus partner stores in money back towards the cost of everyday healthcare, Ipswich, Salford and Colchester. We carry out free home including check-ups, treatment and emergencies. Our assessments to find the right mobility product for our private medical insurance helps individuals and families customers. access treatment at a time and place convenient to them. We have always followed mutual values and care about our We are the UK’s largest health cash plan provider and one communities. Last year we donated £1.6m to health related of the UK’s top five private medical insurance providers. We charities and good causes. In a world where so many people cover nearly four million people with health plans (more than can’t be bothered, we’re proud to be the ones that can. any other company) and 20,000 businesses choose us as their healthcare provider.

16 For more information on any aspect of Simplyhealth, visit: www.simplyhealth.co.uk.

ShARP is funded by Simplyhealth.

17 Did you know: Stats and facts from ShARP

Arthritis is the most common cause of musculoskeletal Endorphins are chemicals in the body produced in the problems in the UK. More than 10 million people a year pituitary gland which damp down pain, but people with consult a doctor about arthritis and more than one in three rheumatoid and psoriatic arthritis have lower than average people over the age of 50 has pain which interferes with their levels, which makes it harder to cope with the condition.26 normal activities.21 Fibromyalgia is a long term condition which causes Back pain will affect four out of five people at some time in widespread pain, is thought to affect one in 20 people and is their lives and more than six million people in the UK suffer usually diagnosed between the ages of 30 and 60.27 from chronic back pain.22 It is estimated to cost £1.6billion Good nutrition is not only important for general health, a year in GP consultations, hospital admissions and other there is now evidence it can reduce muscle wasting as we healthcare expenditure.23 age. Protein, vitamin B12, folic acid and vitamin D are all Calcium is essential for strong, healthy bones. Dairy foods helped to preserve muscle mass.28 are rich in calcium in a readily absorbed form.24 A pint of Heat patches and warming creams relieve pain by dilating semi-skimmed milk provides 690mg of calcium, almost all blood vessels and increasing blood flow to the area, which the entire daily intake of 700mg an adult needs. also promotes healing. Depression is a problem for many people with Ice packs relieve pain and reduce swelling from an injury, musculoskeletal conditions. Three out of five people with the but they won’t reduce muscle damage, as many sports condition feel depressed when their pain is at its worst.25 enthusiasts believe.29

18 Juvenile arthritis affects 12,000 children under the age of Osteoarthritis, the most common form of the condition, is 16 and can strike in infancy. It is thought that a combination caused by wear and tear. More than six million people in the of genetic factors and environmental triggers, which have UK have osteoarthritis in one or both knees and more than not yet been identified, are to blame.30 650,000 have it in one or both hips.34

Knee problems are set to soar as a result of the obesity Profanities increase your pain threshold. A study at Keele epidemic. One study estimates that every kilogram increase University found that volunteers could hold their hand in cold in body weight raises the risk of osteoarthritis of the knee by water for twice as long when they swore. But swearing all between nine and 13 per cent.31 the time dilutes the effect.35

Ligaments connect bone to bone and stabilize joints such Quinine, the ingredient that gives tonic water its bitter taste, as the knee, while tendons link muscle to bone and facilitate is used as a last resort treatment for night time leg cramps.36 movement. Rheumatoid arthritis is an autoimmune condition which can Musculoskeletal conditions are estimated to cost the UK strike at any age and affects three times more women than £5.7billion a year and around 10 million lost working days.32 men. Around 400,000 adults in the UK have been diagnosed with the condition.37 NSAIDs or non-steroidal anti-inflammatory drugs, are commonly taken to relieve aches and pains but can cause Sciatica is pain caused by any compression or irritation of the gastric irritation and, in high doses, can increase the risk of a sciatic nerve, which runs from the pelvis, through the buttocks heart attack.33 to the feet. The most common form is a slipped disc.

19 TENs (transcutaneous electrical nerve stimulation) provide Walking is an ideal form of exercise for anyone with joint an effective treatment for pain and muscle spasm. They pain and has been shown to reduce the pain of arthritis by a deliver bursts of low voltage electricity which helps block third.41 pain signals to the brain. X-ray evidence suggests that around 8.5 million people in Ultrasound is commonly used to treat tendon and ligament the UK have osteoarthritis of the spine.42 injuries and studies suggest it improves mobility and Yoga provides effective pain relief for people with lower reduces pain slightly in patients with osteoarthritis.38 It can back pain and both osteo and rheumatoid arthritis. It also also be used to monitor the effectiveness of treatments for improves mobility and reduces curvature of the spine.43 rheumatoid arthritis.39 Zinc is found in abundance in both the spinal cord and brain Vitamin D deficiency can cause bone pain and tenderness. and numerous studies have shown it acts as a painkiller.44 Sunshine is the best source, but lack of light and the There is also evidence that people with fibromyalgia, a angle of the sun mean most of us have low levels during syndrome characterised by widespread pain, are low in zinc. 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 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

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