The USBJI Board of Directors met four times during 2019, and aside carrying out its regular ongoing fiduciary responsibilities, held a number of strategic discussions.
With the 4th Edition of The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost (BMUS) nearly complete, a number of issues face the Board and BMUS Steering Committee. First among these is a forthcoming change in leadership, and staffing of BMUS. After many years spearheading BMUS with Dr. Stuart Weinstein, Dr. Edward Yelin has indicated it will soon be time for him to step aside. Further, Dr. Sylvia Watkins-Castillo who has worked on all four editions and is the backbone behind production of the publication, working with authors, analyzing the data, preparing the data tables, graphs, drafting much of the content, and more, will be retiring after this edition. The 5th Edition will be the first presenting ICD-10 data. This will necessitate an overhaul of analysis and presentation of the data, including trend data. Given that the next edition is likely to take 3-5 years to produce, the Board is asking what users will expect the 5th Edition to look like by 2023-2025 and what functions they will want it to include? With these and other issues not listed above, the Board expects a critical analysis survey among users of BMUS soon after publication of the 4th Edition, including some user focus groups. Once an idea as to the needs of the future are known, it will begin the search for people with the required leadership and content skills and expertise.
These challenges are similar in one respect to another for the USBJI, and the Global Alliance of Musculoskeletal Health (GMUSC), of which the USBJI is the US arm. Future leadership, and engagement of the generation which will drive our efforts for the next decade —at the GMUSC meeting in Berlin, next June, this will be one topic. Preparing for a meeting to raise the priority of MSK health at the World Health Organization will be another. In the U.S., the Board has encouraged the next generation of thought leaders to take on roles. Dr. Matthew Dobbs became USBJI President in June 2019. Dr. Dobbs has been involved with the organization for many years, first as a participant in the USBJI’s Young Investigator Initiative (YII). Some chapters in BMUS’s 4th Edition have been led by a new generation of authors — Dr. Jaimo Ahn led authorship of the Injuries chapter, Dr. Nicole Wright (also a YII alumni) the Osteoporosis chapter, Dr. Jonathan Kirschner, Neuromuscular, and Dr. Michael Daubs, Spinal Deformity. Dr. Jim Eubanks recorded an excellent overview of the publication which can be viewed under Resources on the site (www.boneandjointburden.org). The USBJI’s Young Investigator Initiative has engaged nearly 500 clinician-scientists and basic scientists studying MSK health. 277 (61%) of these are now funded investigators, and many are rising within their fields as key opinion leaders. We are fortunate to find ourselves with a connection to these YII alumni who have had a positive experience and know the USBJI.
Speaking of our Young Investigator Initiative, by mid-December participants surpassed $500,000,000 in funding awards for MSK research. That funding covers 1,730 new MSK research studies. They and we owe a special debt of gratitude to the generosity of the members of faculty who have given their time and knowledge to mentor these participants, to achieve our goal to increase the pipeline of MSK investigators and thus MSK research. The Board during 2019 authorized a pilot workshop, which was held in collaboration with the Orthopaedic Research and Education Foundation, to extend YII and begin offering workshops for next stage investigators.
At both the June and September meetings the Board reviewed progress of the Musculoskeletal Health Index (MHI) the USBJI is developing. To present prevalence data nationwide on different MSK conditions down to a zip code level, including by Congressional district, and with filters for age, sex, race and ethnicity, the Index could become an important resource, serving research and advocacy interests. The pilot Index presents data on Rheumatoid Arthritis, but the platform is being built to permit data to be presented on other MSK conditions. Development of this is proving more complex than expected, but it is hoped the pilot at least will be ready for release in 2020.
Most of our member societies are prioritizing value in the delivery of healthcare, performance measures and the generation of data to support these. The USBJI is unlikely to start collecting patient outcomes, however it will continue generating prevalence, healthcare utilization and cost data to fill that part of the big picture and need for data on MSK disorders. BMUS and the MHI are key components of this, and essential for research, education, and advocacy.
The Board established a Low Back Pain Task Force in 2019, to recommend USBJI priorities on the most prevalent of MSK disorders – and decided the first need within the field of LBP care is for common definitions and language. See dedicated article in this newsletter.
At the annual meetings of the American Academy of Orthopaedic Surgeons, the American Society for Bone and Mineral Research, and the American College of Rheumatology, the USBJI held roundtables to solicit input on MSK health issues candidates for federal elections in 2020 should include in their healthcare platforms. Called MSK2020, the Board reviewed the input and is pulling this together in a draft position paper. Several member societies have agreed to work with the USBJI on this project and some have already provided guidance and suggestions.
USBJI Secretary, Dr. Bruce Browner, is leading MSK-Ed, a course for medical students pursuing a career in Primary Care. It is vital that Primary Care Providers (PCPs), up to half of whose patients typically have a musculoskeletal disorder, increase their knowledge about these conditions, to speed up timely diagnosis, appropriate referral to MSK specialists, and treatment guidance between appointments with specialists. This is a massive undertaking and the Board discussed progress regularly. It also reviewed the preliminary stages of development of COACH, a version of the USBJI’s Experts in Arthritis patient/public education program which is being developed for Advanced Practitioners to use to educate their patients with arthritis on disease management they should practice at home.
Lastly, the Board has begun a discussion on the level of involvement the USBJI should have on a global level. GMUSC leadership has been focused on attaining recognition for MSK at the World Health Organization, but there has been interest expressed by some in the US about becoming more involved in a broader sense such as how to use the world stage and greater collaboration with experts in other countries to influence innovation and find solutions to improve the treatment of musculoskeletal conditions. The USBJI is currently involved in one such immediate activity with several of its member societies as well as organizations in other countries with similar interests — assisting in preparations for the Fragility Fracture Network (FFN) Global Congress to be held September 24-26, in Toronto. The FFN which up to now has largely been Europe-based, is focused on post-fracture care coordination and secondary fracture prevention. There are sub-organizing committees in Canada, the US, and Latin America.
The USBJI thanks you for taking the time to read about us, for your involvement, and wishes you a productive and prosperous next decade starting in 2020.
The USBJI Board of Directors met four times during 2019, and aside carrying out its regular ongoing fiduciary responsibilities, held a number of strategic discussions.
That dearth of innovation may have been a consequence of the perception that OA is just an inevitable part of aging and something that people just need to “put up with.” Fortunately, that perception is changing rapidly as clinicians and patients alike gain a better understanding of what OA truly is – a serious disease that is associated with a broad range of comorbidities including obesity, cardiovascular disease, diabetes, depression, and early death.
In some ways, the evolution in the understanding and treatment of OA can be seen as analogous to what occurred with rheumatoid arthritis (RA). Over the last two decades, options to help manage symptoms in RA have been supplemented by strategies and new biologic therapies designed to modify the course of disease and improve the ability to maintain or restore function for patients. A range of factors are now driving a similar transition in OA.
While the benefits of lifestyle modifications including exercise and weight loss have been clearly established, OA is affecting people at younger and younger ages, and they are eager for treatment options that can help them address joint pain, preserve their mobility and allow them to remain active. Recently, there has been progress in the development of advanced technologies that provide longer-lasting pain relief. In 2017 we saw the FDA approval of an extended-release corticosteroid specifically indicated for the treatment of OA knee pain. In some ways, that approval marked a renaissance of pharmaceutical innovation in this space.
Today, a cursory search of Clinicaltrials.gov shows more than 800 active trials for OA. This is highly encouraging and serves as proof that both industry and academia are recognizing the pressing need for more innovation in OA. However, by comparison, there are more than 8,000 active trials for cardiovascular disease.
As investigators have gained a better understanding of the disease processes within OA that contribute to pain and structural progression, therapeutic development is rapidly expanding. Patients are likely to benefit from new approaches to provide more effective and durable symptomatic relief, as well as treatments that aim to modify the disease course.
Each year the FFN hosts a conference to bring together individuals who have an interest in the management of fragility fractures with a focus on implementation of evidence-based medicine to improve access and care for patients. The FFN Congress 2020 will be taking place in Toronto, Canada, September 24-26. This is the first time the conference is being hosted outside of Europe and the FFN is excited to be bringing it to North America.
The Congress addresses the full pathway of care for fragility fracture patients, with invited talks from international experts, plenary discussions, interactive update sessions and free papers. The Congress provides a unique platform to learn about new technical developments, state-of-the-art interventions, international research and to interact with leading clinicians, researchers and other professional health workers and stakeholders.
As the first FFN Global Congress to take place outside of Europe the 2020 Congress is symbolic of FFN’s increasing efforts to effect change globally. This year Dr. Jay Magaziner of the University of Maryland School of Medicine became President of the FFN.
Recognizing that post-fracture care requires involvement of professionals from multiple disciplines as well as involvement of family and friends, this year’s motto is “Ensuring Smooth Transitions in Fracture Care and Management.”
The USBJI and several member societies are part of the US Sub-committee planning for and promoting the conference. They invite you to consider submitting a Workshop proposal for the conference, deadline January 31, 2020 – link below. Later there will be a Call for Abstracts for Open Paper Presentations and Posters.
Call for Workshop Proposals
A study appearing in the Nov. 1 issue of the Journal of the AAOS explores why members of racial and ethnic minority groups have a lower rate of acceptance into orthopaedic residency programs, resulting in relative underrepresentation in such programs. Less than 50 percent of applicants from black or Hispanic backgrounds actually enroll in residencies, versus 69 percent of Asian and 73 percent of white applicants. Minorities comprised 29 percent of applicants and 25 percent of enrolled candidates.
Over the 10-year study period, the authors analyzed data on 8,966 applicants from U.S. medical schools for orthopaedic residency and compared outcomes among racial/ethnic groups characterized as white, Asian, black, Hispanic, and other. Quantitative factors used to assess applicants’ academic indicators (United States Medical Licensing Exam [USMLE] Step 1 and 2 Clinical Knowledge [CK] scores, number of publications, Alpha Omega Alpha [AOA] Honor Medical Society status, and volunteer experiences) were then broken down based on racial/ethnic group.
The article noted that orthopaedic surgery residency programs have the lowest representation of racial/ethnic minorities among medical specialties.
Senior author Nadeen O. Chahine, PhD, of Columbia University, and first author Selina Poon, MD, MPH, of Shriners for Children Medical Center in Pasadena, Calif., commented in a joint statement that they undertook the study because, “Looking around us, it is clear that orthopaedic surgery lacks diversity. Residency programs also have low numbers of underrepresented minorities (URMs) among their ranks. We wanted to ask the question of whether differences in residency applicant metrics exist between applicants from different racial/ethnic groups that could partially explain this phenomenon.”
In addition to the basic finding that minorities are underrepresented in residency programs, “The second significant finding is that differences exist in the academic measures within the orthopaedic surgery applicant pool based on race/ethnicity,” the authors said. “White and Asian applicants and matriculated candidates had higher Step 1 scores compared [to] their counterparts. White applicants and matriculated candidates had higher Step 2 CK scores and were more likely to have AOA status than URMs. Hispanic enrolled candidates had a greater number of publications. Black applicants had more volunteer experiences than any other group.”
Another salient and disappointing finding, they said, was that, “The enrollment rates haven’t budged in 10 years, and the disparity in enrollment appears to be getting worse (data [suggest] bigger differences in 2015 compared to 2005).”
The authors said they hoped their findings would assist residency program directors in efforts to increase minority enrollment. They noted, “Our data [suggest] that the practice of setting Step score thresholds for identifying candidates to interview does a disservice as far as diversity is concerned. Perhaps screening candidates based on the totality of the application would improve these trends.”
They noted that other studies have shown that the Medical College Admission Test and the USMLE Step 1 and 2 have unexplained sex and racial/ethnic differences. “We do not have the perfect metric to find the perfect resident yet. Clerkship evaluations and medical school grades may provide a better picture of the applicant.”
Drs. Chahine and Poon’s coauthors of “Underrepresented Minority Applicants Are Competitive for Orthopaedic Surgery Residency Programs, but Enter Residency at Lower Rates” are Kate Nellans, MD, MPH; Alyssa Rothman, MD; Rocio A.L. Crabb, MD; Stephen F. Wendolowski, MS; Daniel Kiridly, MD; Rachel Gecelter, MS; and Prakash Gorroochurn, PhD.
Fig. 1 (A) Scatter plot showing the enrollment rate into orthopaedic surgery residency programs versus application year, by race/ethnic group. (B) Bar diagram showing the average enrollment rate across all years by race/ethnic group. 1 indicates significance versus white, 2 indicates significance versus Asian, 3 indicates significance versus black, 4 indicates significance versus Hispanic, 5 indicates significance versus other. Error bars: standard deviation.
POON S, NELLANS K, ROTHMAN A, ET AL: UNDERREPRESENTED MINORITY APPLICANTS ARE COMPETITIVE FOR ORTHOPAEDIC SURGERY RESIDENCY PROGRAMS, BUT ENTER RESIDENCY AT LOWER RATES. J AM ACAD ORTHOP SURG 2019;27:E957-68
Terry Stanton is the senior science writer for AAOS Now. He can be reached at [email protected].
A new report highlights the latest advances in cell-based therapies for the treatment of disorders of the musculoskeletal system, such as arthritis and osteoporosis, and it identifies key unanswered questions that should be addressed through ongoing research. The report is published in the Journal of Bone and Mineral Research and concurrently in the Journal of Orthopaedic Research, and was issued by a joint Task Force of the American Society for Bone and Mineral Research and the Orthopaedic Research Society.
With cell-based therapies, cells are injected, grafted, or implanted into a patient. Due to the lack of rigorous clinical studies and randomized clinical trials, however, these treatments should be considered experimental. The Task Force provides specific recommendations and ethical considerations for preclinical and clinical investigations of cell-based therapies, and it highlights the importance of determining the direct and indirect effects of these therapies on disease.
“This is an area of enormous public interest and scientific importance,” said lead author and task force co-chair Regis O’Keefe, MD, PhD, of Washington University School of Medicine in St. Louis. “Musculoskeletal diseases such as osteoarthritis, intervertebral disc degeneration, and tendinopathies cause pain, impair function, and can lead to a sense of helplessness. Currently a large number of unproven cell-based therapies are marketed to a vulnerable population of patients that suffer from musculoskeletal disease.” “The goal of the task force was to provide, in an unbiased way, a balanced assessment of the current state of cell-based therapies and to define the scientific agenda needed to develop more proven and effective approaches to treatment in the future,” said task force co-chair Rocky Tuan, PhD, of the Chinese University of Hong Kong.
The Senate Special Committee on Aging has released a bipartisan report on “Falls Prevention: National, State and Local Solutions to Better Support Seniors” (October 16, 2019), with recommendations from U.S. Centers for Medicare & Medicaid (CMS), the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC) for federal, state and local actions to “prevent falls among older adults, and improve falls-related outcomes.” ASBMR former Executive Director Ann Elderkin, P.A., and ASBMR member Cliff Rosen, M.D., were recognized by Senator Susan Collins (ME), who thanked Elderkin and Rosen for a recent letter to the editor published in the Portland Press Herald thanking the Maine delegation for their support of the Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act (S. 283/H.R. 2693). Members from both parties agreed that action is needed to keep older Americans physically and mentally healthy and reduce the costs of fall-related injuries.
In this report, the Senate Special Committee on Aging recommends:
- the “U.S. Department of Health and Human Services (HHS) and other relevant federal departments develop a national education campaign designed to prevent falls and falls-related injuries;
- “continued investment in the development of and expanded access to evidenced-based falls-prevention programs to ensure greater awareness of the risk of falls among older adults and promote preventive steps that can be taken to avoid a fall;”
- that “CMS consider strengthening screening and referral pathways as part of the Medicare Annual Wellness Visit benefit, including taking steps to ensure greater utilization of CDC’s STEADI resources;”
- that “CMS explore avenues that improve access to, and appropriate utilization of, bone density testing;”
- “continued investment in programs that offer home safety evaluations and modifications, as well as improved dissemination of information on public and private resources available for home assessments and modifications;”
- that “CMS consider piloting the CAPABLE model more broadly among qualifying Medicare beneficiaries;”
- that “Congress extend the Money Follows the Person program and encourage greater state adoption;”
- that “CMS continue to explore pilot programs for secondary fracture prevention, including home modifications that are paired with supportive services, and that have been demonstrated to improve utilization of effective screening and therapies, improve outcomes, and reduce costs;”
- that “CMS develop medication review best practices for health care providers to follow as part of the Medicare Annual Wellness Visit. These best practices should include information about how to conduct this review through a lens of falls prevention;”
- and that the “FDA and the National Institutes of Health (NIH) continue to assess the potential impacts of polypharmacy, relationships between medications and falls, specifically medication classes (e.g., anticoagulants) or specific drug combinations (e.g., opioids and benzodiazepines), and how to ensure that older adults are included in clinical trials for drugs in which they will constitute the intended population.”
The Committee’s full report is available here.
The American Physical Therapy Association (APTA) is having a direct impact on the ways physical therapists (PTs) are managing a variety of musculoskeletal issues, thanks to an ongoing collaborative effort to increase the number of clinical practice guidelines (CPGs) developed specifically for the physical therapy profession.
Working primarily with APTA specialty sections, the association provides CPG development workshops, technical support, and funding that allow subject matter experts to provide guidelines firmly rooted in a strong evidence base. Since the program began in 2012, 22 CPGs have been published, with another 34 in development.
Published topics include low back pain, neck pain, shoulder pain, torticollis, hip pain related to osteoarthritis, and more; topics in prepublication stages include PT-related treatment of osteoporosis, shoulder instability, hip fracture, and chronic pain, among others. In 2019, APTA added two new CPGs: one on patellofemoral pain, and another on hand pain and sensory deficits associated with carpal tunnel syndrome. Coming in 2020 is a CPG on PT management of total knee arthroplasty using methodology developed in collaboration with the American Academy of Orthopedic Surgeons.
The development of a CPG is a multiyear, multiphase process that begins with extensive reviews of existing literature, and moves through drafting, appraisal, planning, and external review phases. The final published CPGs represent the state of the evidence as it stands, with a special focus on evidence most relevant to the practice of physical therapists.
For a full list of the CPGs developed by APTA and its sections, visit apta.org/EvidenceResearch/EBPTools/CPGs/APTA/. To find out more about CPGs in development, visit apta.org/EvidenceResearch/EBPTools/CPGs/Update/. Questions? Email [email protected].
The National Association of Orthopaedic Nurses (NAON) released a Position Statement this fall regarding the role of the Orthopaedic Nurse Navigator. Given the fast pace of change in the current healthcare landscape, the Orthopaedic Nurse Navigator is able to contribute greatly to improved patient outcomes.
This position statement outlines key elements to the role as well as common themes found in orthopaedic programs across the nation. The Navigator holds a key role on the interdisciplinary team as the single point of contact to coordinate care both in and outside the hospital setting. With the introduction of value-based payment, the nurse navigator/care coordination model has been proven essential to improving outcomes while decreasing costs and readmissions. The Orthopaedic Nurse Navigator focuses on patient advocacy, care coordination, disease-specific education and data management to improve outcomes and patient satisfaction during the transitions through the continuum. The nurse in this role is able to facilitate pre-operative preparation, manage expectations of care and facilitate transition home. The Nurse Navigator demonstrates accountability for evidence based patient education and knowledge of care coordination in order to facilitate the patient’s journey through the healthcare continuum. Additionally, the Orthopaedic Nurse Navigator is an expert in data collection, tracking and trending to improve processes and outcomes based on evidence based clinical practice. Click here to view the statement.
If you have any questions please e-mail NAON Headquarters at [email protected]
Led by nationally recognized physician, Dr. Heidi Prather, a clinician and professor at Washington University School of Medicine and former president of the North American Spine Society, the USBJI Low Back Pain Task Force is focusing on the development of recommendations for language and communication of back pain.
Heidi Prather, DO, Professor, Physical Medicine and Rehabilitation
Washington University School of Medicine
The group was initially charged with developing a recommendation on what aspects of low back pain the USBJI should prioritize, and its role in addressing these with the community of many organizations concerned with low back pain. They debated identifying diagnostic dilemmas, management dilemmas, gaps in research, unmet needs, all associated with lower back pain. These challenges are reflected in the wide variation in diagnosis and language, an aging population, inflammatory causes of back pain, special populations with back pain such as children and the elderly, the transition from acute to chronic back pain, biases of provider groups, the impact of ‘first touch’, lack of standardization of management and the plethora of treatment options, the impact of the internet on patients’ knowledge base about back pain, escalating costs, escalating disability, and more.
In choosing to focus on the language and communication of back pain, the Task Force is asking: can we remove inaccurate and catastrophizing language, can we promote some standardization for the most commonly seen conditions? Language is the most fundamental aspect of back pain that affects all the challenges of back pain. All work by the Task Force emphasizes a patient-centered, evidence-based approach, with special attention to the biopsychosocial nature of lower back pain.
Addressing language and communication, as well as the truly multidisciplinary nature of the Task Force, breaks down the traditional ‘silo’ based nature of back pain and provides a framework for developing care coordination.
The Task Force was organized at the behest of USBJI president Dr. Matthew Dobbs and the USBJI Board. Convened in March 2019, it includes a second former president of the North American Spine Society, Dr. F. Todd Wetzel. Members include representatives from the chiropractic profession, the physical therapy profession, athletic training profession, as well as medical specialists with backgrounds in rheumatology, physical medicine and rehabilitation, spine surgery and pain management. Several members have extensive backgrounds in research.
The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are dedicated to increasing research of musculoskeletal diseases. To keep pace with the high and increasing burden of these diseases, a higher level of research performed by young investigators in the musculoskeletal diseases is required, and future levels of research assured. This is particularly important given the current environment for research funding, and academic careers. In response, the Young Investigator Initiative is a grant mentoring and career development program providing early-career investigators an opportunity to work with experienced researchers in our field to assist them in securing funding and other survival skills required for pursuing an academic career.
This grant mentoring and career development program is open to promising junior faculty, senior fellows or post-doctoral researchers nominated by their department or division chairs seeking to pursue a career in clinical or basic research. It is also open to senior fellows or residents that are doing research and have a faculty appointment in place or confirmed. Basic and clinical investigators, without or with training awards, are invited to apply. Investigators selected to take part in the program attend two workshops, 12-18 months apart, and work with faculty between workshops to develop their grant applications. The unique aspect of this program is the opportunity for attendees to maintain a relationship with a mentor until their application is funded. The Spring 2020 workshop is scheduled to take place on April 24-26, in Rosemont, IL (Chicago). The deadline for applications for this workshop is January 15, 2020.
Fall 2019 Workshop Toronto, Canada
For more about the program and detailed application instructions, please refer to www.usbji.org/programs/yii.
Movement is Life (MiL), dedicated to health disparities for people with musculoskeletal conditions, primarily arthritis, celebrated its 10-year anniversary in 2019. A podcast series of interviews placing MiL as #1 in the health disparities space was launched - The Health Disparities Podcast. A Congressional Bill was introduced, and a hearing on it was held just before the MIL Annual Caucus meeting began.
At the MIL annual caucus in November Dr. David Williams and Dr. Fatima Cody of Stanford returned as keynote speakers addressing social determinants of health and obesity. Dr. David Ronald Musgrove, former Governor of Mississippi, gave an insightful and entertaining perspective of how to impact change in social determinants of health through legislation. Dr. Claire Pomeroy gave an informative talk on health equity accelerating the bend toward justice.
The closing keynote speaker, Father Gregory J. Boyle, spoke on The People We Throw Away - Inclusion a Path Toward Health Equity. Father Boyle is a Jesuit Priest who founded Homeboy Industries, the largest gang intervention, rehabilitation and re-entry program in Los Angeles.
Group breakout sessions on activism and movement addressed understanding the impact of your zip code, rural health, and on integrating mindfulness or yoga techniques for you or your practice.
Dr. Vani Sabesan is the USBJI’s representative to Movement is Life.
Experts in Arthritis patient/public education: www.ControlArthritis.org
Fit to a T (fracture prevention/bone health/osteoporosis) patient/public education: www.fit2t.org
Grant Mentoring and Career Development for MSK researchers: www.usbji.org/programs/yii
Movement is Life (Disparities): www.movementislifecaucus.com
OA Action Alliance: www.oaation.unc.edu
Secondary Fracture Prevention Initiative: www.secondaryfractures.org
United States Bone and Joint Initiative (USBJI): www.usbji.org