The economic cost of musculoskeletal disorders in Canada

"Gleaning a lot from the history and physical exam," and "reasonably confident without imaging": a qualitative study of primary care clinicians' management of patients with low back pain

BACKGROUND

Routine seeking of imaging for patients with low back pain is not concordant with the evidence-based recommendation that imaging is rarely of diagnostic value. Inappropriate imaging is a waste of resources and can lead to undesirable downstream effects for individuals and health systems. To develop effective strategies to reduce unwarranted referrals for imaging in primary care, we must understand the drivers for, and barriers to, guideline-adherent practice. We explored clinicians' views to identify the dominant influences on clinicians as they choose to pursue, or avoid, imaging for their patients with low back pain.

METHODS

We interviewed a purposeful sample of 47 primary care clinicians (14 physiotherapists, 18 chiropractors, 15 physicians) throughout Ontario, Canada, with a guide based on the Theoretical Domains Framework (TDF). We investigated clinicians' views about their use of imaging in the management of low back pain. Interviews were recorded and transcribed verbatim. We analysed transcripts, then identified themes within TDF domains.

RESULTS

Most clinicians reported that, for most clinical encounters, they adhered to guideline recommendations about imaging. Many clinicians across disciplines expressed the following themes: (1) imaging may result in an incidental finding or otherwise cause harm to patients, and drive up health system costs (TDF domain Beliefs about consequences); (2) clinicians were confident in their abilities to diagnose, to explain to patients the rationale for not recommending imaging, and to respond to their needs (domains Beliefs about capabilities; Skills). Many clinicians identified that patients occasionally want the validation that imaging provides (domain Social influences). Some clinicians described the value of imaging to corroborate a diagnosis (domain Beliefs about consequences).

CONCLUSIONS

This study is the first to examine influences on imaging behaviours of a large interprofessional sample of primary care clinicians in Canada. Even among knowledgeable, skilled, confident clinicians who reported mostly adhering to guideline recommendations, there are potential influences on deviating from guideline-adherent care.

The prevalence of occupational-related low back pain among working populations in sub-saharan Africa: a systematic review and meta-analysis

INTRODUCTION

Work-related musculoskeletal disorders represent a major public health problem, contributing significantly to the global burden of disability-adjusted life years and affecting the quality of life of all population groups. The main problem in most musculoskeletal disorders is low back pain. Therefore, our study aims to identify the overall prevalence of work-related low back pain among the working population in sub-Saharan Africa.

METHODS

Research published between 2010 and 2023 in English, conducted in Sub-Saharan Africa was included in this systematic review and meta-analysis. Using Boolean logic operators and targeted keywords, we searched for publications on a number of electronic databases (Web of Science, PubMed, Google Scholar, African Journals Online (AJOL), and Science Direct). The Joanna Briggs Institute Critical Appraisal techniques were utilized to conduct a quality assessment of the papers and ascertain their relevance to the study. The degree of heterogeneity among the included studies, the 95% confidence interval, and the pooled prevalence were estimated using a random effects model. Sensitivity studies were carried out to determine the causes of heterogeneity and the impact of outliers.

RESULTS

In this study, a total of 970 articles were retrieved, and 35 studies were included in the systematic review and meta-analysis. The overall estimated pooled prevalence of low back pain among the working population in sub-Saharan Africa was (55.05% [95% CI: 49.34, 60.76]). Based on a sub-group analysis by countries, the higher pooled prevalence of low back pain was found in Uganda at (61.48% [95% CI: 40.39, 82.57]), while the lower pooled prevalence of low back pain was in Ghana at (34.48% [95% CI: 17.96, 51.01]).

CONCLUSIONS

This systematic review and meta-analysis found that 55.05% of the included study participants experienced low back pain in the previous years. Therefore, it is recommended that policymakers incorporate and enhance strategies for the prevention and management of low back pain within the health system management guidelines of each country.

Online Ergonomic Evaluation in Realistic Manual Material Handling Task: Proof of Concept

Work-related musculoskeletal disorders are globally one of the leading causes of work-related injuries. They significantly impact worker health and business costs. Work task ergonomic risk indices have been developed that use observational assessments to identify potential injuries, and allow safety managers to promptly intervene to mitigate the risks. However, these assessments are very subjective and difficult to perform in real time. This work provides a technique that can digitalize this process by developing an online algorithm to calculate the NIOSH index and provide additional data for ergonomic risk assessment. The method is based on the use of inertial sensors, which are easily found commercially and can be integrated into the industrial environment without any other sensing technology. This preliminary study demonstrates the effectiveness of the first version of the Online Lifting Index (On-LI) algorithm on a common industrial logistic task. The effectiveness is compared to the standard ergonomic assessment method. The results report an average error of 3.6% compared to the NIOSH parameters used to calculate the ergonomic risk and a relative error of the Lifting Index of 2.8% when compared to observational methods.

A global comparative study of wealth-pain gradients: Investigating individual- and country-level associations

Pain is a significant yet underappreciated dimension of population health. Its associations with individual- and country-level wealth are not well characterized using global data. We estimate both individual- and country-level wealth inequalities in pain in 51 countries by combining data from the World Health Organization's World Health Survey with country-level contextual data. Our research concentrates on three questions: 1) Are inequalities in pain by individual-level wealth observed in countries worldwide? 2) Does country-level wealth also relate to pain prevalence? 3) Can variations in pain reporting also be explained by country-level contextual factors, such as income inequality? Analytical steps include logistic regressions conducted for separate countries, and multilevel models with random wealth slopes and resultant predicted probabilities using a dataset that pools information across countries. Findings show individual-level wealth negatively predicts pain almost universally, but the association strength differs across countries. Country-level contextual factors do not explain away these associations. Pain is generally less prevalent in wealthier countries, but the exact nature of the association between country-level wealth and pain depends on the moderating influence of country-level income inequality, measured by the Gini index. The lower the income inequality, the more likely it is that poor countries experience the highest and rich countries the lowest prevalence of pain. In contrast, the higher the income inequality, the more nonlinear the association between country-level wealth and pain reporting such that the highest prevalence is seen in highly nonegalitarian middle-income countries. Our findings help to characterize the global distribution of pain and pain inequalities, and to identify national-level factors that shape pain inequalities.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia

OBJECTIVES

To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.

DESIGN

We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.

SETTING

Australian primary care.

PARTICIPANTS

Registered physiotherapists who are members of a practice-based research network (n=31).

RESULTS

The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.

CONCLUSION

High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis

BACKGROUND

Advanced practice physiotherapy (APP) models of care where physiotherapists are primary contact emergency department (ED) providers are promising models of care to improve access, alleviate physicians' burden, and offer efficient centered patient care for patients with minor musculoskeletal disorders (MSKD).

OBJECTIVES

To compare the effectiveness of an advanced practice physiotherapist (APPT)-led model of care with usual ED physician care for persons presenting with a minor MSKD, in terms of patient-related outcomes, health care resources utilization, and health care costs.

METHODS

This trial is a multicenter stepped-wedge cluster randomized controlled trial (RCT) with a cost analysis. Six Canadian EDs (clusters) will be randomized to a treatment sequence where patients will either be managed by an ED APPT or receive usual ED physician care. Seven hundred forty-four adults with a minor MSKD will be recruited. The main outcome measure will be the Brief Pain Inventory Questionnaire. Secondary measures will include validated self-reported disability questionnaires, the EQ-5D-5L, and other health care utilization outcomes such as prescription of imaging tests and medication. Adverse events and re-visits to the ED for the same complaint will also be monitored. Health care costs will be measured from the perspective of the public health care system using time-driven activity-based costing. Outcomes will be collected at inclusion, at ED discharge, and at 4, 12, and 26 weeks following the initial ED visit. Per-protocol and intention-to-treat analyses will be performed using linear mixed models with a random effect for cluster and fixed effect for time.

DISCUSSION

MSKD have a significant impact on health care systems. By providing innovative efficient pathways to access care, APP models of care could help relieve pressure in EDs while providing efficient care for adults with MSKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05545917 . Registered on September 19, 2022.

Exploring the relationship between kinematic variability and fatigue development during repetitive lifting

To investigate the variability-fatigue and repeaters-replacers hypotheses, motor variability (MV) and indicators of fatigue were assessed during repetitive lifting. Eighteen participants performed sequential repetitive bouts of lifting divided into a short bout, and three phases of a prolonged bout until volitional fatigue (or until a 1-h time limit). Whole-body kinematics were collected to calculate variability in three-dimensional joint angles and in continuous relative phase (CRP) of sagittal joint angle couplings, which were summed for the upper and lower body, and whole-body. Excellent individual consistency (ICC = 0.95-0.97) was demonstrated across lifting bouts as fatigue developed. Therefore, strong evidence was obtained for MV as an individual trait in support of the repeaters-replacers hypothesis. Associations were found for endurance and baseline effort with lower body variability, while no associations were found for rate of fatigue. Thus, some support was found for the variability-fatigue hypothesis which suggests that repeaters are less fatigue-resistant than replacers.

Brain-specific genes contribute to chronic but not to acute back pain

Introduction

Back pain is the leading cause of disability worldwide. Although most back pain cases are acute, 20% of acute pain patients experience chronic back pain symptoms. It is unclear whether acute pain and chronic pain have similar or distinct underlying genetic mechanisms.

Objectives

To characterize the molecular and cellular pathways contributing to acute and chronic pain states.

Methods

Cross-sectional observational genome-wide association study.

Results

A total of 375,158 individuals from the UK Biobank cohort were included in the discovery of genome-wide association study. Of those, 70,633 (19%) and 32,209 (9%) individuals met the definition of chronic and acute back pain, respectively. A total of 355 single nucleotide polymorphism grouped into 13 loci reached the genome-wide significance threshold (5x10^-8) for chronic back pain, but none for acute. Of these, 7 loci were replicated in the Nord-Trøndelag Health Study (HUNT) cohort (19,760 chronic low back pain cases and 28,674 pain-free controls). Single nucleotide polymorphism heritability was 4.6% (P=1.4x10^-78) for chronic back pain and 0.81% (P=1.4x10-8) for acute back pain. Similar differences in heritability estimates between acute and chronic back pain were found in the HUNT cohort: 3.4% (P=0.0011) and 0.6% (P=0.851), respectively. Pathway analyses, tissue-specific heritability enrichment analyses, and epigenetic characterization suggest a substantial genetic contribution to chronic but not acute back pain from the loci predominantly expressed in the central nervous system.

Conclusion

Chronic back pain is substantially more heritable than acute back pain. This heritability is mostly attributed to genes expressed in the brain.

Occupational-Related Upper and Lower Extremity Musculoskeletal Pain Among Working Population of Ethiopia: Systematic Review and Meta-Analysis

Background:

Currently, work-related musculoskeletal disorders are a significant public health concern and are a leading cause of disability-adjusted life years and reduced quality of life worldwide. In developing countries, including Ethiopia, as a result of poor occupational health and safety practices and underreporting of the problems, work-related musculoskeletal disorders have been increased, remaining less prioritized, and there is no adequate evidence on the prevalence of musculoskeletal disorders. Thus, the current study aimed to determine and provide the overall prevalence of occupational-related upper and lower extremity musculoskeletal pain among the working population of Ethiopia.

Methods

The current study considered full-text articles conducted in Ethiopia, written in English, and published from 2017 to 2020. Ten electronic databases: PubMed/MEDLINE, Web of Science, SCOPUS, Google Scholar, MedNar, Embase, CINAHL, Cochrane Library, African Index Medicus, and African Journals Online database were used to search the articles using a combination of Boolean logic operators (AND, OR, and NOT), Medical Subject Headings, and main keywords. The quality assessment of the articles was performed using the Joanna Briggs Institute Critical Appraisal tools to determine the relevance of the article to the current study.

Results:

Of the 1377 articles identified from the included electronic databases, 12 studies were included in the systematic review and meta-analysis. The study found that the pooled prevalence of occupational-related elbow pain, wrist/hand pain, knee/leg pain, foot/ankle pain, and hip/thigh pain in the previous one year was 19.7% (95% CI: 12.3, 30.1), 24.2% (95% CI: 17.4, 32.7), 25.0% (95% CI: 18.5, 32.8), 20.2% (95% CI: 12.8, 30.4), and 15.5% (95% CI: 9.9, 23.4), respectively. Based on a subgroup analysis, the last year’s pooled prevalence of occupational-related elbow, wrist/hand, knee/leg, foot/ankle, and hip/thigh pain was increased to 33.7% [95% CI: 31.9, 35.5], 29.7% [95% CI: 28.2, 31.2], 31.5% [95% CI: 29.9, 33.2], 30.6% [95% CI: 29.0, 32.4], and 27.3% [95% CI: 25.5, 29.2], respectively.

Conclusion:

Occupational-related musculoskeletal disorders continue to have a potential impact on workers’ health and productivity. The current study found that the overall pooled prevalence of occupational-related upper and lower extremity musculoskeletal disorders in the last year ranged from 15.5 to 33.7%. Implementing occupational health and safety measures play an important role in preventing work-related musculoskeletal disorders and other occupational hazards.

Single session compared with multiple sessions of education and exercise for older adults with spinal pain in an advanced practice physiotherapy model of care: protocol for a randomised controlled trial

OBJECTIVES

To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care.

METHODS AND ANALYSIS

In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1-a single session or 2-multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants' healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Comité d'éthique de la recherche du CIUSS de l'Est-de-l'Île-de-Montréal (FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences.

PROTOCOL VERSION

V.4 August 2021.

TRIAL REGISTRATION NUMBER

NCT04868591; Pre-results.

How does Gender Influence Sustainable Return to Work Following Prolonged Work Disability? An Interpretive Description Study

PURPOSE

A sustainable return to work (S-RTW) following prolonged work disability poses different challenges, depending on gender. This article provides a synthesis of gender differences in the issues and factors influencing the S-RTW of workers following such a disability.

METHODS

Using an interpretive description method, an integrative review was conducted of the literature on gender differences in S-RTW issues and factors associated with four major causes of work disability. The initial review concerned the 2000-2016 literature; it was subsequently updated for November 2016-March 2020. To explore and contextualise the results, four focus groups were held with stakeholders representing the workplace, insurance, and healthcare systems and workers. Qualitative thematic analysis was performed.

RESULTS

A total of 47 articles were reviewed, and 35 stakeholders participated in the focus groups. The prevailing traditional gender roles were found to have a major gender-specific influence on the attitudes, behaviours, processes and outcomes associated with S-RTW. These differences related to the (1) cumulative workload, (2) work engagement, and (3) expressed and addressed needs.

CONCLUSIONS

The results highlight the importance of taking into account both professional and personal aspects when integrating gender issues into the assessment of workers' needs and subsequently into interventions.

Analyzing musculoskeletal risk prevalence among workers in developing countries: an analysis of small-scale cast-iron foundries in India

Musculoskeletal disorders (MSDs) are the most common health issues around the globe and a major cause of disability among workers. In developing countries, most casting industries fall under Small and Medium Scale Enterprises (SMEs); SMEs lack modern equipment and often intensively rely on manual labor. As processes are mainly labor intensive, workers employed in the metal casting sector are often at risk of MSDs. The main objective of this study is to investigate the exposure of work-related musculoskeletal symptoms prevalent among male workers employed in small scale gray cast-iron foundries of northern India. The techniques used included the Nordic Musculoskeletal Questionnaire (NMQ), anthropometric measures, work postures analysis based on digital human modeling (DHM), Rapid Upper Limb Assessment/RULA and Biomechanics Single Action Analysis/BSAA ergonomic assessment tools. Based on the measured anthropometric variables and work postures attained during various routine tasks, virtual work manikins were created and analyzed using human activity analysis in CATIA V5R20. Subjective assessment revealed that distal upper extremity regions i.e. wrists/hands followed by lower back, neck and shoulders have higher frequency of reported MSDs symptoms. Higher musculoskeletal risk was observed with most of the analyzed work postures, with fettling and Manual Material Handling (MMH) tasks being the most affected. A regression model was developed to predict the L4-L5 spine compression load on the workers' lumbar regions; a coefficient of determination (R²) value of 0.761 indicates an acceptable model fit (R-value = 0.873). Based on the values of the standardized beta coefficients, findings suggested that trunk angle (β = 0.616), followed by upper arm angle (β = 0.408), were stronger predictors on the dependent variable (i.e. L4-L5 spine compression) than population percentile (β = 0.372), object weight (β = 0.208) and lower arm angle (β = 0.183). The findings suggest that factors like manual work demands, poor work station structure, repetitive actions and awkward postures held for a longer duration may likely be associated with MSDs risk severity. The present study may guide the foundry industrialists in analyzing the mismatch between the workers' job profiles and redesigning the work station layouts in small scale foundries based on minimizing the risk severity associated with the tasks carried out by staff.

Methodological considerations in the assessment of direct and indirect costs of back pain: A systematic scoping review

BACKGROUND

Back pain is a common and costly health problem worldwide. There is yet a lack of consistent methodologies to estimate the economic burden of back pain to society.

OBJECTIVE

To systematically evaluate the methodologies used in the published cost of illness (COI) literature for estimating the direct and indirect costs attributed to back pain, and to present a summary of the estimated cost burden.

METHODS

Six electronic databases were searched to identify COI studies of back pain published in English up to February 2021. A total of 1,588 abstracts were screened, and 55 full-text studies were subsequently reviewed. After applying the inclusion criteria, 45 studies pertaining to the direct and indirect costs of back pain were analysed.

RESULTS

The studies reported data on 15 industrialised countries. The national cost estimates of back pain in 2015 USD ranged from $259 million ($29.1 per capita) in Sweden to $71.6 billion ($868.4 per capita) in Germany. There was high heterogeneity among the studies in terms of the methodologies used for analysis and the resulting costs reported. Most of the studies assessed costs from a societal perspective (n = 29). The magnitude and accuracy of the reported costs were influenced by the case definition of back pain, the source of data used, the cost components included and the analysis method. Among the studies that provided both direct and indirect cost estimates (n = 15), indirect costs resulting from lost or reduced work productivity far outweighed the direct costs.

CONCLUSION

Back pain imposes substantial economic burden on society. This review demonstrated that existing published COI studies of back pain used heterogeneous approaches reflecting a lack of consensus on methodology. A standardised methodological approach is required to increase credibility of the findings of COI studies and improve comparison of estimates across studies.

A randomized controlled trial investigating effects of an individualized pedometer driven walking program on chronic low back pain

BACKGROUND

Walking is an easily prescribed physical activity for people with low back pain (LBP). However, the evidence for its effectiveness to improve pain and disability levels for people with chronic low back pain (CLBP) within a community setting has not been evaluated. This study evaluates the effectiveness of a clinician guided, pedometer-driven, walking intervention for increasing physical activity and improving clinical outcomes compared to education and advice.

METHODS

Randomized controlled trial recruiting N = 174 adults with CLBP. Participants were randomly allocated into either a standardized care group (SG) or pedometer based walking group (WG) using minimization allocation with a 2:1 ratio to the WG. Prior to randomization all participants were given a standard package of education and advice regarding self-management and the benefits of staying active. Following randomization the WG undertook a physiotherapist guided pedometer-driven walking program for 12 weeks. This was individually tailored by weekly negotiation of daily step targets. Main outcome was the Oswestry Disability Index (ODI) recorded at baseline, 12 weeks, 6 and 12 months. Other outcomes included, numeric pain rating, International Physical Activity Questionnaire (IPAQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Back Beliefs questionnaire (BBQ), Physical Activity Self-efficacy Scale, and EQ-5D-5L quality of life estimate.

RESULTS

N = 138 (79%) participants completed all outcome measures at 12 weeks reducing to N = 96 (55%) at 12 months. Both observed and intention to treat analysis did not show any statistically significant difference in ODI change score between the WG and the SG at all post-intervention time points. There were also no significant between group differences for change scores in all secondary outcome measures. Post hoc sensitivity analyses revealed moderately disabled participants (baseline ODI ≥ 21.0) demonstrated a greater reduction in mean ODI scores at 12 months in the WG compared to SG, while WG participants with a daily baseline step count < 7500 steps demonstrated a greater reduction in mean ODI scores at 12 weeks.

CONCLUSIONS

Overall, we found no significant difference in change of levels of (ODI) disability between the SG and WG following the walking intervention. However, ODI responses to a walking program for those with moderate levels of baseline disability and those with low baseline step count offer a potential future focus for continued research into the benefit of walking as a management strategy for chronic LBP.

TRIAL REGISTRATION

United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 (27/10/2014).

Trends in Pain Prevalence among Adults Aged 50 and Older across Europe, 2004 to 2015

Objectives: We examine recent trends in pain prevalence among adults aged 50+ across Europe. Methods: Data for 15 countries from the Survey of Health, Ageing, and Retirement in Europe are examined for two periods: 2004-2011 and 2013-2015. Trends are shown descriptively, using a multilevel modeling strategy controlling for covariates, and modeled on a country-specific basis. Results: Population-level pain prevalence ranges from about 30% to about 60% depending on the country and year. Pain is more prevalent in women and generally increases with age. There is an increase in prevalence over time, net of age, and other predictors. Prevalence increased with an annual average of 2.2% between 2004 and 2011 and 5.8% between 2013 and 2015, in fully adjusted models. Discussion: Trends in pain prevalence have implications for disability, healthcare utilization, productivity, and population health. These findings are not optimistic but align with other population-wide studies, suggesting a global trend of rising pain prevalence.

Deconstructing the Joint Examination: A Novel Approach to Teaching Introductory Musculoskeletal Physical Examination Skills for Medical Students

Introduction

Musculoskeletal (MSK) disorders are very common, but suboptimal teaching of MSK medicine occurs and expert clinicians agree that MSK physical examination (PE) skills can be confusing and complicated for medical students. An innovative approach in introductory teaching of MSK PE skills was developed using constructivist theory for second-year medical students.

Methods

We implemented the MSK PE curriculum innovation in the second year of a four-year MD program, utilizing a standard framework with spaced practice and clinician coaching. We evaluated this curriculum by comparing the innovation group (n = 123) to a historical control group (n = 134) using an anonymous survey and OSCE station scores. Data analysis included repeated measures analysis of variance comparing students' self-confidence in MSK PE to students' self-confidence in other systems-based PEs, as well as independent t-test comparisons of self-confidence scores and MSK-specific OSCE station scores between the historical and innovation groups.

Results

The mean self-assessed confidence of the historical group was significantly lower for the MSK PE than all other PEs (p < 0.001), except for the neurological PE. Significant improvement in MSK PE self-confidence was noted with the innovation group (t(259) = -4.05, p < 0.001). OSCE scores significantly improved in MSK-specific stations, with medium to large effect size across the different stations.

Discussion

We successfully used a framework of deconstruction, repetition, and spaced practice to develop fundamental MSK PE skills in preclerkship medical students. This curriculum structure provides an effective example for teaching introductory MSK PE skills to early medical learners.

Development and Investigation of a Wearable Aid for a Load Carriage Task

Anterior load carriage tasks are common and can lead to musculoskeletal disorders such as lower back pain. The objectives of this study were to develop a wearable carriage aid and examine its effectiveness on physical demands while considering the potential moderating influence of the carried load. The study consisted of two within-subject factors: device and load. For the former, two levels were tested: with and without the device worn. For the latter, two loads were examined: 15 and 30% of each individual’s body mass. Sixteen participants walked on a treadmill for five minutes at a constant speed for each condition. Physical demands were quantified using objective (EMG-based) and subjective (discomfort) measures. Wearing the device reduced static and median anterior deltoid, trapezius, and biceps brachii muscle activations. Increasing the carried load increased most physical demand measures. Two significant Device×Load interactions were observed; for the anterior deltoid and trapezius median activation measures, the influence of increasing load was lower when the device was worn. While slightly increasing perceived discomfort in the lower back, wearing the device reduced shoulder, neck, and hand/wrist discomfort. While the study demonstrated a potential for the device, future work is required under more realistic and diverse testing conditions.

Previous High School Participation in Varsity Sport and Jump-Landing Biomechanics in Adult Recreational Athletes

CONTEXT

Early sports sampling is associated with superior biomechanics in youth athletes; however, the effect of multisport participation on adult biomechanics is unknown.

OBJECTIVE

To compare jump-landing biomechanics between adult recreational athletes who previously participated in 0, 1, or 2 or more select high school varsity sports (VSs; basketball, lacrosse, soccer, volleyball) that feature landing and cutting tasks.

DESIGN

Descriptive laboratory study.

SETTING

University community setting.

PATIENTS OR OTHER PARTICIPANTS

Fifty adult recreational athletes (22 women, 28 men; age = 23.8 ± 2.5 years) with no high school VS experience or with high school VS experience in basketball, lacrosse, soccer, or volleyball. Athletes were grouped into those who participated in 0 (0VS, n = 11), 1 (1VS, n = 21), or 2 or more (2VSs, n = 18) of these sports at the high school level.

MAIN OUTCOME MEASURE(S)

The average Landing Error Scoring System (LESS) total score from 3 individual jump landings was determined. A 1-way analysis of covariance using sex as the covariate was calculated to compare groups. The Pearson R was used to test for the correlation between the LESS score and number of sports played, and a linear regression analysis was performed using the number of sports played to predict the LESS score. The α level was set a priori at .05.

RESULTS

The 0VS athletes produced similar LESS scores as the 1VS athletes (5.89 ± 1.2 versus 5.38 ± 1.93 points, respectively, P = .463), whereas the 2VSs athletes demonstrated lower LESS scores (3.56 ± 1.97 points) than the 0VS (P = .002) and 1VS (P = .004) athletes. The LESS scores were moderately negatively correlated with the number of high school VSs played (R² = -0.491, P < .001). The linear regression analysis was significant (F_1,37 = 9.416, P = .004) with R² = 0.203. For every additional VS played at the high school level, the LESS score decreased by 1.28 points.

CONCLUSIONS

Landing Error Scoring System scores were lower in athletes who had a history of multisport high school varsity participation in basketball, lacrosse, soccer, or volleyball compared with those who had a history of single-sport or no participation in these sports at this level. Multisport high school varsity participation in these sports may result in improved neuromuscular performance and potentially reduced injury risks as adults.

Comparative clinical and cost analysis between surgical and non-surgical intervention for knee osteoarthritis

OBJECTIVE

To evaluate the management and costs of osteoarthritis of the knee (OAK), a progressive joint disease due to bone and cartilage degeneration, with significant personal and societal impact.

METHODS

We prospectively analyzed the clinical outcomes and quantifiable cumulative direct costs of patients with OAK referred to our multidisciplinary OA program over a two year time period. One hundred thirty-one subjects were assessed. All demonstrated radiographic criteria for moderate to severe OAK. Western Ontario McMaster Osteoarthritis Index (WOMAC), Minimal Clinically Important Improvement (MCII), and change in BMI were recorded and analyzed. Total medical and surgical direct costs for all subjects during the two year time period were determined.

RESULTS

Five patients underwent total joint replacement during the two years of study. Among the group as a whole, a significant overall improvement in WOMAC scores was noted at the two year time point follow-up. After dividing the group into tertiles by baseline WOMAC scores, 46% achieved MCII. Significant weight loss was noted for individuals with baseline BMI of > 30. As all patients were considered "de facto" surgical candidates at referral, an average net savings of $9551.10 of direct costs per patient, or a potential total of $1,203,438.60 for the entire group, could be inferred as a result of medical as opposed to surgical management.

CONCLUSION

These findings support the benefits of multidisciplinary medical management for patients with significant OAK. This approach is clinically beneficial and may provide significant cost savings. Such models of care can substantially improve the long-term outcome of this highly prevalent condition and reduce societal and financial burdens.

The impact of work-related risk factors on the development of neck and upper limb pain among low wage hotel housekeepers in Gondar town, Northwest Ethiopia: institution-based cross-sectional study

Background

Musculoskeletal disorders are a major source of disability accounting for considerable economic loss globally. Studies showed that housekeepers suffer from exposure to many high-risk factors for neck and upper limb musculoskeletal disorders. In Ethiopia, little is known and the information is limited in scope about the magnitude of the problem among hotel housekeepers. Therefore, this study aimed to determine the magnitude of the neck and upper limb musculoskeletal disorders and identify the associated risk factors among hotel housekeepers.

Methods

Institution-based cross-sectional study design was employed from March 1 to May 20, 2017. Systematic random sampling was used to select 422 study participants among the Gondar town hotels, Ethiopia. The standardized Nordic questionnaire for the analysis of musculoskeletal symptoms was used to measure the neck and upper limb musculoskeletal disorders. Bivariate and multivariable binary logistic regression analyses were performed using SPSS version 20. The significance level was obtained at 95% CI and p value ≤ 0.05.

Results

The overall magnitude of a self-reported neck and upper limb musculoskeletal disorders among hotel housekeepers in the last 12 months was 62.8% (95% CI 58.3, 67.8). The main body areas of concern were neck pain (50.7%), shoulder pain (54%), elbow/forearm (47.2%), and hand/wrist (45.5%). Age, rest break taken, repetitive movement, reaching/overstretching, organization concern for health and safety, and job satisfaction were the risk factors significantly associated with neck and upper limb musculoskeletal disorders.

Conclusions

A higher proportion of hotel housekeepers were found to be affected by neck and upper limb musculoskeletal disorders in Gondar town. Repetitive movement and reaching/overstretching were strongly associated risk factors with neck and upper limb musculoskeletal disorders. Therefore, ergonomic, organizational and personal measures, which focus on minimizing repetitive movement and awkward working position and facilitating rest break with exercise, are important to tackle neck and upper limb musculoskeletal disorders among hotel housekeepers.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study

BACKGROUND

At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings.

METHODS

The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients.

DISCUSSION

This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

The association between awkward working posture and low back disorders in farmers: a systematic review

BACKGROUND

Low back disorders (LBD) are the most common musculoskeletal problem among farmers, with higher prevalence than other occupations. Although studies of the general population have shown an association between LBD and awkward working posture, farmers have unique work context and exposures that may modify this relationship. This review aimed to 1) identify published research studies investigating posture as a risk factor for LBD in farmers/agricultural workers, and 2) determine the strength of the relationship between postural exposure and LBD risk of bias assessment.

METHOD

Comprehensive electronic searches of Medline, Web of Science, CINAHL, SCOPUS, PubMed, and EMBASE were carried out with combined conceptual groups of search terms for 'farming' and 'LBD.' After screening, data were extracted to summarize the study design, sample characteristics, exposure assessment methods, LBD risk factors, demographic information, data collection methods, farm commodities, job context, and sampling strategy. Data were synthesized to determine the weight of evidence for awkward working posture as a risk factor for LBD among farmers.

RESULTS

Nine studies were included in this review. All studies used self-report; there were no field-based studies including direct measurement of awkward posture. There was diversity in exposure definition, exposure assessment, LBD definition, worker characteristics, and analytical approaches. There was evidence to support association between awkward working posture and LBD among farmers.

CONCLUSION

Despite the diversity, the weight of evidence supported a relationship between awkward posture and LBD. Well-designed epidemiological studies with quantitative physical workload assessments, consistent and valid LBD definitions, and longitudinal designs are recommended to clarify the relationship between awkward posture and LBD.

The Status of Musculoskeletal Disorders and Its Influence on the Working Ability of Oil Workers in Xinjiang, China

The purpose of this study was to investigate the status of musculoskeletal disorders (MSDs) and its influence on the working ability of oil workers, and to provide a theoretical basis for helping lessen the burden of MSDs and improve the man-machine environment of oil workers. The cluster sampling method was used to study 2000 workers who had been employed for more than 1 year in this field. We investigated the prevalence rate and the work ability index (WAI). A total of 1935 valid questionnaires were collected, a response rate of 96.75%. There were 1639 people who had suffered from MSDs in the past year, a prevalence rate of 84.7%. The damage detection rate in female oil workers was higher than in males, and the damage detection rate in workers aged 30 to 45 years was higher than that in the other two age groups. The detection rate in less highly-educated oil workers was higher than that in more highly-educated workers. The detection rate in divorced workers was higher than that in other groups. The detection rate in workers between the number of working years of 18 to 25 years was higher than in the other two groups. The detection rate in workers with a high professional title was significantly higher than that in lower-titled workers (p < 0.05). The results showed that the WAI scores of the subjects with MSDs were significantly lower than for subjects without MSDs (p < 0.05). In a logistic regression analysis, sex, number of working years and WAI index all had an impact on MSDs. We concluded that due to the demands of their role, the oil workers had serious MSDs that influenced their working ability.

Use of low level of continuous heat and Ibuprofen as an adjunct to physical therapy improves pain relief, range of motion and the compliance for home exercise in patients with nonspecific neck pain: A randomized controlled trial

BACKGROUND

It has been well documented at heat reduces pain and increases healing by increasing blood flow in tissue.

OBJECTIVE

The purpose of this study was to see if the use of low level continuous heat (LLCH) and Ibuprofen used as a home therapy between physical therapy sessions at a clinic resulted in better therapy outcomes in people with chronic neck pain.

METHODS

Ninety-two patients with chronic nonspecific neck pain were randomly divided into 4 groups; LLCH group, LLCH with Ibuprofen (IP) group, sham LLCH with sham IP group, and controls. All subjects underwent 45 minutes of conventional physical therapy twice a week for 2 weeks. the neck disability index (NDI), subjective pain, range of motion (ROM), strength of the neck, and home exercise compliance were measured.

RESULTS

Both LLCH and IP significantly reduced pain and NDI score, and increased ROM (p< 0.01). Home exercise compliance in LLCH and LLCH with IP group was significantly higher than the placebo and control groups (p < 0.05).

CONCUSION

The use of LLCH alone and LLCH with IP as an adjunct to conventional physical therapy for chronic neck pain significantly improved pain attenuation and it causes greater compliance for home.

The effects of continuity of care on hospital utilization in patients with knee osteoarthritis: analysis of Nationwide insurance data

BACKGROUND

Korea's rapidly aging population has led to a rise in the prevalence of knee osteoarthritis (which reached upwards of 21.3% in 2017) in elderly people aged 65 years and over. Most patients with knee osteoarthritis require ongoing management in the community or through primary care. Continuity of care is a desirable attribute of primary care. However, previous studies on the association between continuity of care and health outcomes have focused on specific disease populations, particularly diabetes mellitus and hypertension. The objectives of this study were to determine whether there is an association between continuity of care for outpatients with knee osteoarthritis and health outcomes.

METHODS

We conducted a cohort study using claims data from 2014. The study population included 131,566 patients. We measured hospital admission and medical costs during the final 3 months and the continuity of care by Most Frequent Provider Continuity (MFPC), Modified Modified Continuity Index (MMCI), and Continuity of Care (COC) index in the 9 preceding months, using multiple logistic regression analyses to determine which index best explains continuity. We evaluated the relationship between COC and hospital admissions, using negative binomial regression analysis due to over-dispersion. Finally, multiple regressions were used to examine the relationship between the COC and medical costs.

RESULTS

We selected the COC index to determine the association between hospital admission and cost; the area under the receiver operating characteristic curve (AUC) of the COC was the largest (0.904), while those for the MFPC (0.894) and MMCI (0.893) were similar. The negative binomial regression analysis showed that continuity of care was significantly related to hospitalization, with the relative risk (RR) of hospital admission being low for patients with high continuity of care [RR = 27.17 for those with the reference group COC (0.76-1.00); 95% CI, 3.09-3.51]. Continuity of care was significantly related to medical costs after considering other covariates. A higher COC index was associated with a lower cost.

CONCLUSIONS

Higher continuity of care for knee osteoarthritis patients might decrease hospital admission and medical costs.

Use of Western Medicine and Traditional Korean Medicine for Joint Disorders: A Retrospective Comparative Analysis Based on Korean Nationwide Insurance Data

This study aimed to compare the usage of Western medicine and traditional Korean medicine for treating joint disorders in Korea. Data of claims from all medical institutions with billing statements filed to HIRA from 2011 to 2014 for the four most frequent joint disorders were used for the analysis. Data from a total of 1,100,018 patients who received medical services from 2011 to 2014 were analyzed. Descriptive statistics are presented as type of care and hospital type. All statistical analyses were performed using IBM SPSS for Windows version 21. Of the 1,100,018 patients with joint disorders, 456,642 (41.5%) were males and 643,376 (58.5%) were females. Per diem costs of hospitalization in Western medicine clinics and traditional Korean medicine clinics were approximately 160,000 KRW and 50,000 KRW, respectively. Among costs associated with Western medicine, physiotherapy cost had the largest proportion (28.78%). Among costs associated with traditional Korean medicine, procedural costs and treatment accounted for more than 70%, followed by doctors' fees (21.54%). There were distinct differences in patterns of medical care use and cost of joint disorders at the national level in Korea. This study is expected to contribute to management decisions for musculoskeletal disease involving joint disorders.

Systematic review of quantitative imaging biomarkers for neck and shoulder musculoskeletal disorders

Background

This study systematically summarizes quantitative imaging biomarker research in non-traumatic neck and shoulder musculoskeletal disorders (MSDs). There were two research questions: 1) Are there quantitative imaging biomarkers associated with the presence of neck and shoulder MSDs?, 2) Are there quantitative imaging biomarkers associated with the severity of neck and shoulder MSDs?

Methods

PubMed and SCOPUS were used for the literature search. One hundred and twenty-five studies met primary inclusion criteria. Data were extracted from 49 sufficient quality studies.

Results

Most of the 125 studies were cross-sectional and utilized convenience samples of patients as both cases and controls. Only half controlled for potential confounders via exclusion or in the analysis. Approximately one-third reported response rates. In sufficient quality articles, 82% demonstrated at least one statistically significant association between the MSD(s) and biomarker(s) studied. The literature synthesis suggested that neck muscle size may be decreased in neck pain, and trapezius myalgia and neck/shoulder pain may be associated with reduced vascularity in the trapezius and reduced trapezius oxygen saturation at rest and in response to upper extremity tasks. Reduced vascularity in the supraspinatus tendon may also be a feature in rotator cuff tears. Five of eight studies showed an association between a quantitative imaging marker and MSD severity.

Conclusions

Although research on quantitative imaging biomarkers is still in a nascent stage, some MSD biomarkers were identified. There are limitations in the articles examined, including possible selection bias and inattention to potentially confounding factors. Recommendations for future studies are provided.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1694-y) contains supplementary material, which is available to authorized users.

Supervisors' perceptions of organizational policies are associated with their likelihood to accommodate back-injured workers

Background Low back pain (LBP) is a major concern among North American workplaces and little is known regarding a supervisor's decision to support job accommodation for workers with LBP. The extent to which supervisors are included in a company's effort to institute disability management policies and practices and workplace safety climate are two factors that may influence a supervisor's decision to accommodate workers with LBP. Objective Determine the association between supervisors' perceptions of disability management policies, corporate safety culture and their likelihood of supporting job accommodations for workers with LBP. Methods We conducted a cross-sectional study of supervisors (N=796) recruited from a non-random, convenience sample of 19 Canadian and US employers. The outcome was supervisors' likeliness to support job accommodation and the exposure was global work safety culture and disability management policies and practices. A multivariable generalized linear modelling strategy was used and final models for each exposure were obtained after assessing potential effect modifiers and confounders. Results In the study, 796 eligible supervisors from 19 employers participated. Disability management policies and practices were positively associated with supervisors' likeliness to accommodate (β=0.19; 95% CI: 0.13; 0.24) while no significant association was found between corporate safety culture (β= -0.084; 95% CI: -0.19; 0.027) and supervisors' likeliness to accommodate. Conclusions Employers should ensure that proactive disability management policies and practices are clearly communicated to supervisors in order to improve job modification and return to work efforts. Implications for Rehabilitation Low back pain (LBP) is a major workplace concern and little is known regarding what factors are associated with a supervisor's likelihood to support job accommodation for workers with LBP. The objective of this article was to determine the association between supervisors' perceptions of disability management policies and practices, corporate safety culture and their likelihood of support job accommodations for workers with LBP. Results suggest that disability management policies and practices are positively associated with supervisors' likelihood to accommodate while corporate safety culture is not. These results are important for employers as it suggests that employers should ensure that their disability management policies and practices are clearly communicated to supervisors in order to improve job accommodation and return to work efforts.

Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Musculoskeletal disease in Nepal: A countrywide cross-sectional survey on burden and surgical access

INTRODUCTION

Musculoskeletal disease (MSD) is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in low and middle-income countries (LMICs) are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure incidence and prevalence of surgically treatable conditions, including MSD, in patients in LMICs.

METHODS

A countrywide survey was done in Nepal using SOSAS in May-June 2014. Clusters were chosen based on population weighted random sampling. Chi squared tests and multivariate logistic regression assessed associations between demographic variables and MSD.

RESULTS

Self-reported MSDs were seen in 14.8% of survey respondents with an unmet need of 60%. The majority of MSDs (73.9%) occurred between 1 and 12 months prior to the survey. Female sex (OR = 0.6; p < 0.000), access to motorized transport (for secondary facility, OR = 0.714; p < 0.012), and access to a tertiary health facility (OR = 0.512; p < 0.008) were associated with lower odds of MSD.

DISCUSSION

Based on this study, there are approximately 2.35 million people living with MSDs in Nepal. As the study identified non-availability, lack of money, and fear and/or lack of trust as the major barriers to orthopedic care in Nepal, future work should consider interventions to address these barriers.

CONCLUSION

There is a need to increase surgical capacity in LMICs; in particular, there is a need to bolster trauma and orthopedic care. Previous studies have suggested ways to allocate resources to build capacity. We recommend targeting the alleviation of these identified barriers in parallel with capacity building.

Predictive value of the DASH tool for predicting return to work of injured workers with musculoskeletal disorders of the upper extremity

OBJECTIVES

To determine whether the Disabilities of the Arm, Shoulder, and Hand (DASH) tool added to the predictive ability of established prognostic factors, including patient demographic and clinical outcomes, to predict return to work (RTW) in injured workers with musculoskeletal (MSK) disorders of the upper extremity.

METHODS

A retrospective cohort study using a population-based database from the Workers' Compensation Board of Alberta (WCB-Alberta) that focused on claimants with upper extremity injuries was used. Besides the DASH, potential predictors included demographic, occupational, clinical and health usage variables. Outcome was receipt of compensation benefits after 3 months. To identify RTW predictors, a purposeful logistic modelling strategy was used. A series of receiver operating curve analyses were performed to determine which model provided the best discriminative ability.

RESULTS

The sample included 3036 claimants with upper extremity injuries. The final model for predicting RTW included the total DASH score in addition to other established predictors. The area under the curve for this model was 0.77, which is interpreted as fair discrimination. This model was statistically significantly different than the model of established predictors alone (p<0.001). When comparing the DASH total score versus DASH item 23, a non-significant difference was obtained between the models (p=0.34).

CONCLUSIONS

The DASH tool together with other established predictors significantly helped predict RTW after 3 months in participants with upper extremity MSK disorders. An appealing result for clinicians and busy researchers is that DASH item 23 has equal predictive ability to the total DASH score.

The economic impact of early retirement attributed to rheumatic diseases: results from a nationwide population-based epidemiologic study

OBJECTIVES

To measure early retirement due to self-reported rheumatic diseases (RDs) and to estimate the respective indirect costs and years of working life lost (YWLL).

METHODS

We used individual level data from the national, cross-sectional, population-based EpiReumaPt study (September 2011-December 2013) where 10,661 inhabitants were randomly surveyed in order to capture and characterize all cases of RD within a representative sample of the Portuguese population. In this analysis, we used all participants aged between 50 and 64 years, near the official retirement age. A national database was used to calculate productivity values by gender, age and region, using the human capital approach. YWLL were estimated as the difference between each participant's current age and the respective retirement age, while the potential years of working life lost (PYWLL) were given by the difference between official and actual retirement ages. We also calculated the percentage of time in inactivity (inactivity ratio = YWLL/Active age-range [15-64 years old]).

RESULTS

29.9% of the Portuguese population with ages between 50 and 64 years were retired with 13.1% self-reporting retirement due to RD. The estimated annual indirect cost following premature retirement attributed to RD was €910 million (€555 per capita; €1625 per self-reported RD patient and €13,592 per early retiree due to RD). Females contributed with 84% for these costs (€766 million; €882 per capita vs €187 from males). We observed a total number of 389,939 accumulated YWLL (228 per 1000 inhabitants) and 684,960 PYWLL (401 per 1000 inhabitants). The mean YWLL and PYWLL inactivity ratios were 12% and 21%, respectively. RD patients with higher values of disability have the highest risk of early retirement.

CONCLUSIONS

Early retirement attributed to self-reported RD amounts to approximately 0.5% of the national gross domestic product (GDP) in 2013, due to large YWLL. Both the public health concern and the economic impact highlight the need to prioritize investments in health and social protection policies targeting patients with rheumatic conditions.

Prevalence of musculoskeletal pain of the neck, upper extremities and lower back among dental practitioners working in Riyadh, Saudi Arabia: a cross-sectional study

OBJECTIVES

Studies have shown that dentists have a higher incidence of work-related musculoskeletal (MSK) pain than those in other occupations. The risk factors contributing to MSK pain among Saudi dentists has not been fully studied so this study aims to estimate the prevalence of MSK pain and investigate its associated risk factors among dentists in Saudi Arabia.

SETTING AND PARTICIPANTS

A cross-sectional survey was carried out in the capital city Riyadh, Saudi Arabia, using random cluster sampling. 224 surveys were distributed among dentists with a 91.1% response rate (101 women and 103 men).

OUTCOMES

The prevalence of MSK pain and its associated risk factors were investigated.

RESULTS

184 (90.2%) respondents reported having MSK pain. Lower back pain was the most commonly reported MSK pain (68.1%). Gender and age were reported to be predictors for at least one type of MSK pain. Older age was associated with lower back pain (OR 1.23; 95% CI 1.00 to 1.50) and women had double the risk of shoulder pain (OR 2.52; 95% CI 1.12 to 5.68). In addition, lower back pain was related to the time the dentist spent with patients (OR 0.28; 95% CI 0.14 to 0.54), while shoulder pain (OR 1.03; 95% CI 1.00 to 1.06) and lower back pain (OR 1.06; 95% CI 1.03 to 1.10) were significantly related to years of experience.

CONCLUSIONS

MSK pain is common among older and female Saudi dentists. Research on the impact of exercise and the ergonomics of the workplace on the intensity of MSK pain and the timing of its onset is required.

Sex-based differences in lifting technique under increasing load conditions: A principal component analysis

The objective of the present study was to determine if there is a sex-based difference in lifting technique across increasing-load conditions. Eleven male and 14 female participants (n = 25) with no previous history of low back disorder participated in the study. Participants completed freestyle, symmetric lifts of a box with handles from the floor to a table positioned at 50% of their height for five trials under three load conditions (10%, 20%, and 30% of their individual maximum isometric back strength). Joint kinematic data for the ankle, knee, hip, and lumbar and thoracic spine were collected using a two-camera Optotrak motion capture system. Joint angles were calculated using a three-dimensional Euler rotation sequence. Principal component analysis (PCA) and single component reconstruction were applied to assess differences in lifting technique across the entire waveforms. Thirty-two PCs were retained from the five joints and three axes in accordance with the 90% trace criterion. Repeated-measures ANOVA with a mixed design revealed no significant effect of sex for any of the PCs. This is contrary to previous research that used discrete points on the lifting curve to analyze sex-based differences, but agrees with more recent research using more complex analysis techniques. There was a significant effect of load on lifting technique for five PCs of the lower limb (PC1 of ankle flexion, knee flexion, and knee adduction, as well as PC2 and PC3 of hip flexion) (p < 0.005). However, there was no significant effect of load on the thoracic and lumbar spine. It was concluded that when load is standardized to individual back strength characteristics, males and females adopted a similar lifting technique. In addition, as load increased male and female participants changed their lifting technique in a similar manner.

Cross-Sectional Contrast Between Individuals With Foot/Ankle vs Knee Osteoarthritis for Obesity and Low Education on Health-Related Quality of Life

BACKGROUND

Improving health-related quality of life (HRQoL) necessitates an understanding of the influence of patient characteristics on, and interrelationship among, HRQoL domains. In osteoarthritis (OA), these associations have predominantly been examined in hip/knee populations. We investigated whether there were differences in these associations between foot/ankle and knee OA samples.

METHODS

Individuals seeking orthopedic care for foot/ankle or knee OA completed a questionnaire pre-consultation, including HRQoL domains (bodily pain [BP], physical [PF] and social functioning [SF], and mental [MH] and general health [GH]), obesity, comorbidity, and sociodemographic characteristics. Associations were examined via stratified path analysis (foot/ankle vs knee). Foot/ankle: n = 180, mean age = 55 (range: 25 to 82), 52% female. Knee: n = 253, mean age = 62 (range: 26 to 92), 51% female.

RESULTS

The interrelationship among HRQoL domains was generally similar between groups. However, the influence of patient characteristics differed. Low educational status was associated with worse scores for GH, MH, and SF in the foot/ankle group, whereas no significant effects were found in the knee group. Obesity was associated with worse scores for SF, BP, and GH in the foot/ankle compared to the knee group. Patient characteristics explained considerably more of the variation in domain scores in the foot/ankle group.

CONCLUSION

There are significant differences in the impact of patient characteristics on HRQoL domains in foot/ankle versus knee OA patients. Therefore, a universal approach to patient education/intervention to improve HRQoL in lower-extremity OA is not likely to achieve optimal results. Based on these findings, we recommend joint-specific patient education, with a particular emphasis on patient characteristics among the foot/ankle OA population.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Epidemiology of rheumatic diseases in Mixtec and Chontal indigenous communities in Mexico: a cross-sectional community-based study

This study aimed to estimate the prevalence of musculoskeletal (MSK) disorders and rheumatic diseases in the Chontal and Mixtec indigenous communities in the state of Oaxaca, Mexico, using the Community-Oriented Program for the Control of Rheumatic Diseases (COPCORD) methodology. After cross-culturally validating the COPCORD questionnaire for these communities, we conducted a cross-sectional, analytical, community-based census study using a house-to-house method. Positive cases of MSK disorders were assessed by primary care physicians and rheumatologists. The study population included participants aged ≥18 years from the indigenous communities of San Antonio Huitepec and San Carlos Yautepec. A total of 1061 persons participated in the study. Mean age was 46.9 years (standard deviation 19.9; age range 18–97 years); 642 (60.5 %) were women; 483 participants (45.5; 42.4–48.5 %) had MSK pain in the previous 7 days. Diagnoses were back pain 170 (16.0 %; 95 % confidence interval [CI] 13.8–18.3); osteoarthritis 157 (14.7 %; 95 % CI 12.7–17.0); rheumatic regional pain syndrome 53 (4.9 %; 95 % CI 3.7–6.4); rheumatoid arthritis 4 (0.3 %; 95 % CI 0.1–0.9); dermatomyositis 1 (0.09 %; 95 % CI 0.0–0.5); ankylosing spondylitis 1 (0.09 %; 95 % CI 0.0–0.5); systemic lupus erythematosus 1 (0.09 %; 95 % CI 0.02–0.5); and gout 1 (0.09 %; 95 % CI 0.0–0.5). 53.2 % had not received medical treatment for their disease. The prevalence of MSK disorders in indigenous communities in the Mixtec and Chontal regions is very high. The most common rheumatic diseases found were back pain and osteoarthritis. A high percentage of participants had not received medical care.

Supervisor Autonomy and Considerate Leadership Style are Associated with Supervisors' Likelihood to Accommodate Back Injured Workers

PURPOSE

To determine the association between supervisors' leadership style and autonomy and supervisors' likelihood of supporting job accommodations for back-injured workers.

METHODS

A cross-sectional study of supervisors from Canadian and US employers was conducted using a web-based, self-report questionnaire that included a case vignette of a back-injured worker. Autonomy and two dimensions of leadership style (considerate and initiating structure) were included as exposures. The outcome, supervisors' likeliness to support job accommodation, was measured with the Job Accommodation Scale (JAS). We conducted univariate analyses of all variables and bivariate analyses of the JAS score with each exposure and potential confounding factor. We used multivariable generalized linear models to control for confounding factors.

RESULTS

A total of 796 supervisors participated. Considerate leadership style (β = .012; 95% CI .009-.016) and autonomy (β = .066; 95% CI .025-.11) were positively associated with supervisors' likelihood to accommodate after adjusting for appropriate confounding factors. An initiating structure leadership style was not significantly associated with supervisors' likelihood to accommodate (β = .0018; 95% CI -.0026 to .0061) after adjusting for appropriate confounders.

CONCLUSIONS

Autonomy and a considerate leadership style were positively associated with supervisors' likelihood to accommodate a back-injured worker. Providing supervisors with more autonomy over decisions of accommodation and developing their considerate leadership style may aid in increasing work accommodation for back-injured workers and preventing prolonged work disability.

An investigation of the validity of the Work Assessment Triage Tool clinical decision support tool for selecting optimal rehabilitation interventions for workers with musculoskeletal injuries

OBJECTIVE

To evaluate the concurrent validity of a clinical decision support tool (Work Assessment Triage Tool (WATT)) developed to select rehabilitation treatments for injured workers with musculoskeletal conditions.

DESIGN

Methodological study with cross-sectional and prospective components.

SETTING

Data were obtained from the Workers' Compensation Board of Alberta rehabilitation facility in Edmonton, Canada.

SUBJECTS

A total of 432 workers' compensation claimants evaluated between November 2011 and June 2012.

MAIN MEASURES

Percentage agreement between the Work Assessment Triage Tool and clinician recommendations was used to determine concurrent validity. In claimants returning to work, frequencies of matching were calculated and compared between clinician and Work Assessment Triage Tool recommendations and the actual programs undertaken by claimants. The frequency of each intervention recommended by clinicians, Work Assessment Triage Tool, and case managers were also calculated and compared.

RESULTS

Percentage agreement between clinician and Work Assessment Triage Tool recommendations was poor (19%) to moderate (46%) and Kappa = 0.37 (95% CI -0.02, 0.76). The Work Assessment Triage Tool did not improve upon clinician recommendations as only 14 out of 31 claimants returning to work had programs that contradicted clinician recommendations, but were consistent with Work Assessment Triage Tool recommendations. Clinicians and case managers were inclined to recommend functional restoration, physical therapy, or no rehabilitation while the Work Assessment Triage Tool recommended additional evidence-based interventions, such as workplace-based interventions.

CONCLUSIONS

Our findings do not provide evidence of concurrent validity for the Work Assessment Triage Tool compared with clinician recommendations. Based on these results, we cannot recommend further implementation of the Work Assessment Triage Tool. However, the Work Assessment Triage Tool appeared more likely than clinicians to recommend interventions supported by evidence; thus warranting further research.

Walking away from back pain: one step at a time - a community-based randomised controlled trial

BACKGROUND

Low back pain is highly prevalent and a significant public health burden in Western society. Feasibility studies suggest personalised pedometer-driven walking is an acceptable and effective motivating tool in the management of chronic low back pain (CLBP ≥ 12 weeks). The proposed study will investigate pedometer-driven walking as a low cost, easily accessible, and sustainable means of physical activity to improve disability and clinical outcomes for people with CLBP in Saskatchewan, Canada.

METHODS/DESIGN

A fully-powered single-blinded randomised controlled trial will compare back care advice and education with back care advice and education followed by a 12-week pedometer-driven walking programme in adults with CLBP. Adults with self-reported CLBP will be recruited from the community and screened for elibility. Two-hundred participants will be randomly allocated to one of two intervention groups. All participants will receive a single back care advice and education session with a physiotherapist. Participants in the walking group will also receive a physiotherapist-facilitated pedometer based walking programme. The physiotherapist will facilitate the participant to monitor and progress the walking programme, by phone, on a weekly basis over 10 weeks following two face-to-face sessions. Outcome measures of self-reported disability, physical activity, participants' low back pain beliefs/perceptions, quality of life and direct/indirect cost estimates will be gathered at baseline, three months, six months, and 12 months by a different physiotherapist blinded to group allocation. Following intervention, focus groups will be used to explore participants' thoughts and experiences of pedometer-driven walking as a management tool for CLBP.

DISCUSSION

This paper describes the design of a community-based RCT to determine the effectiveness of a pedometer-driven walking programme in the management of CLBP.

TRIAL REGISTRATION

United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 . Registered on 27(th) October 2014).

A new muscle co-activation index for biomechanical load evaluation in work activities

Low-back disorders (LBDs) are the most common and costly musculoskeletal problem. Muscle co-activation, a mechanism that stabilises the spine, is adopted by the central nervous system to provide added protection and avoid LBDs. However, during high-risk lifting tasks, the compressive load on the spine grows owing to increased co-activation. The aim of this study was to develop a method for the sample-by-sample monitoring of the co-activation of more than two muscles, and to compare this method with agonist-antagonist methods. We propose a time-varying multi-muscle co-activation function that considers electromyographic (EMG) signals as input. EMG data of 10 healthy subjects were recorded while they manually lifted loads at three progressively heavier conditions. The repeated measures ANOVA revealed a significant effect of lifting condition on our co-activation index. Heavier conditions resulted in higher muscle co-activation values. Significant correlations were found between the time-varying multi-muscle co-activation index and other agonist-antagonist methods. Practitioner Summary: We have developed a method to quantify muscle co-activation during the execution of a lifting task. To do this we used surface electromyography. Our algorithm provides a measure of time-varying co-activation between more than two muscles.

The effect of presenteeism-related health conditions on employee work engagement levels: A comparison between groups

Orientation: Awareness of presenteeism-related health conditions is important as the prevalence of these conditions unknowingly influences performance and productivity in organisations.Research purpose: The primary objective of this study was to determine the differences in work engagement levels based on groups of presenteeism-related conditions in employees.Motivation for the study: Awareness of the impact of presenteeism-related conditions on work engagement levels can aid in the crafting of interventions to assist employees who suffer from these conditions, which in turn can boost work engagement levels.Research design, approach and method: Cross-sectional data was collected from an availability sample of employees in the manufacturing sector (N = 3387).Main findings: The results of the multi-group structural equation modelling revealed significant mean differences in work engagement levels between the groups. Practical significance tests revealed significant differences between all the groups. The largest difference was between the group who suffered from no presenteeism-related conditions and the group who suffered from all three conditions included in this study concurrently.Practical/managerial implications: Organisational stakeholders are encouraged to take note of the effects that presenteeism-related health conditions have on work engagement and to consider relevant strategies and interventions to address and alleviate symptoms in order to tend to employee health and obviate the effect on productivity.Contribution: This study found that there were clear practical differences between employees who suffer from the presenteeism-related conditions and those who suffer from none of the conditions. Furthermore, there was also a clear difference when comparing the ‘no condition’ group to a general random sample in which employees might experience some symptoms but not comorbidity.

Age, physical inactivity, obesity, health conditions, and health-related quality of life among patients receiving conservative management for musculoskeletal disorders

Background

Musculoskeletal conditions and insufficient physical activity have substantial personal and economic costs among contemporary aging societies. This study examined the age distribution, comorbid health conditions, body mass index (BMI), self-reported physical activity levels, and health-related quality of life of patients accessing ambulatory hospital clinics for musculoskeletal disorders. The study also investigated whether comorbidity, BMI, and self-reported physical activity were associated with patients’ health-related quality of life after adjusting for age as a potential confounder.

Methods

A cross-sectional survey was undertaken in three ambulatory hospital clinics for musculoskeletal disorders. Participants (n=224) reported their reason for referral, age, comorbid health conditions, BMI, physical activity levels (Active Australia Survey), and health-related quality of life (EQ-5D). Descriptive statistics and linear modeling were used to examine the associations between age, comorbidity, BMI, intensity and duration of physical activity, and health-related quality of life.

Results

The majority of patients (n=115, 51.3%) reported two or more comorbidities. In addition to other musculoskeletal conditions, common comorbidities included depression (n=41, 18.3%), hypertension (n=40, 17.9%), and diabetes (n=39, 17.4%). Approximately one-half of participants (n=110, 49.1%) self-reported insufficient physical activity to meet minimum recommended guidelines and 150 (67.0%) were overweight (n=56, 23.2%), obese (n=64, 28.6%), severely obese (n=16, 7.1%), or very severely obese (n=14, 6.3%), with a higher proportion of older patients affected. A generalized linear model indicated that, after adjusting for age, self-reported physical activity was positively associated (z=4.22, P<0.001), and comorbidities were negatively associated (z=−2.67, P<0.01) with patients’ health-related quality of life.

Conclusion

Older patients were more frequently affected by undesirable clinical attributes of comorbidity, obesity, and physical inactivity. However, findings from this investigation are compelling for the care of patients of all ages. Potential integration of physical activity behavior change or other effective lifestyle interventions into models of care for patients with musculoskeletal disorders is worthy of further investigation.

Development and validation of the ankle fracture outcome of rehabilitation measure (A-FORM)

STUDY DESIGN

Delphi panel and cohort study.

OBJECTIVE

To develop and refine a condition-specific, patient-reported outcome measure, the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), and to examine its psychometric properties, including factor structure, reliability, and validity, by assessing item fit with the Rasch model.

BACKGROUND

To our knowledge, there is no patient-reported outcome measure specific to ankle fracture with a robust content foundation.

METHODS

A 2-stage research design was implemented. First, a Delphi panel that included patients and health professionals developed the items and refined the item wording. Second, a cohort study (n = 45) with 2 assessment points was conducted to permit preliminary maximum-likelihood exploratory factor analysis and Rasch analysis.

RESULTS

The Delphi panel reached consensus on 53 potential items that were carried forward to the cohort phase. From the 2 time points, 81 questionnaires were completed and analyzed; 38 potential items were eliminated on account of greater than 10% missing data, factor loadings, and uniqueness. The 15 unidimensional items retained in the scale demonstrated appropriate person and item reliability after (and before) removal of 1 item (anxious about footwear) that had a higher-than-ideal outfit statistic (1.75). The "anxious about footwear" item was retained in the instrument, but only the 14 items with acceptable infit and outfit statistics (range, 0.5-1.5) were included in the summary score.

CONCLUSION

This investigation developed and refined the A-FORM (Version 1.0). The A-FORM items demonstrated favorable psychometric properties and are suitable for conversion to a single summary score. Further studies utilizing the A-FORM instrument are warranted. J Orthop Sports Phys Ther 2014;44(7):488-499. Epub 22 May 2014. doi:10.2519/jospt.2014.4980.

A profile of farmers and other employed Canadians with chronic back pain: a population-based analysis of the 2009-2010 Canadian community health surveys

PURPOSE

Chronic back disorders (CBDs) are a serious public health issue, both in the general population and among farmers. However, it is not clear whether all individuals with CBD should be treated the same, or if some subpopulations have special needs. This study's purpose was to determine the demographic, socioeconomic, co-morbidity, and other health characteristics of Canadian farmers and nonfarmers with self-reported CBD.

METHODS

We performed a secondary analysis of the 2009-2010 Canadian Community Health Survey to develop a profile of adults with CBD comparing farmers (N = 350) to nonfarmer employed persons (N = 11,251). In addition to descriptive analysis, multiple logistic regression was used to control for possible confounding.

FINDINGS

Our results indicate that farmers with CBD are significantly more likely to be older, less educated, and more often male and living rurally than nonfarmers with CBD. We found no difference between rates and type of co-morbidities between farmers and nonfarmers. However, the sociodemographic differences between farmers and nonfarmers with CBD may impact the design of effective interventions and have implications for health services planning and health care delivery. The information presented is anticipated to help address the identified need for musculoskeletal disorder prevention in agriculture.

Determining the pain-affecting factors of university students with nonspecific low back pain

[Purpose] This study was conducted on university students with nonspecific low back pain in order to determine the independent variables that affect their pain. [Methods] A total of 514 students were included in this study. Pain was evaluated using a Visual Analogue Scale (VAS). A special form was prepared in order to evaluate the following independent variables: gender, weight, height, Body Mass Index (BMI), working periods sitting straight (television, computer, seminar, etc.), working periods bending at a table (reading, writing, etc.), using lumbar support while sitting, the mean duration of pain within the last one year, type of pain, time of the pain, faculty, class, physical activity habits and smoking. The collected data were evaluated using the CHAID (Chi-squared Automatic Interaction Detection) analysis method. [Results] The working hours bending at a table, physical activity, height, weight, BMI and educational departments were found not to affect the severity of the pain. The pain severity was affected by the duration of pain complaints within the last one year, the duration of working staying upright, smoking, classes, usage of lumbar support and age variables. [Conclusions] The results of this study show that nonspecific low back pain of university students is affected by many factors such as smoking, class, age, using a computer and lumbar support.