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

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,
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