Global health policy in the 21st century: Challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions

Role of Nutrition in the Management of Patients with Chronic Musculoskeletal Pain

Chronic musculoskeletal pain (CMP), defined as persistent discomfort in musculoskeletal tissues persisting for over 3 months, afflicts an estimated 1.71 billion people globally, leading to significant functional impairments and psychological distress, thereby detrimentally affecting individuals' quality of life. The objective of this narrative review is to elucidate the complex relationship among dietary habits, sarcopenia, and gut microbiota composition, with an eye toward enhancing patient management and outcomes. Given the burgeoning interest in the influence of diet on CMP, a detailed examination of the current literature is warranted. Nutritional intake is a critical determinant of the gut microbiota profile, which, in turn, is linked to musculature integrity and performance, potentially leading to sarcopenia. The development of sarcopenia can aggravate CMP owing to diminished muscular strength and functionality. Additionally, disruptions in the gut microbiota may directly modulate nociception, intensifying CMP manifestations. Thus, nutritional optimization emerges as a viable approach to CMP management. Emphasizing a diet conducive to a healthy gut microbiome could forestall or mitigate sarcopenia, thereby attenuating CMP intensity. Nevertheless, the domain calls for further empirical exploration to unravel the nuances of these interactions and to forge efficacious dietary strategies for individuals with CMP. Beyond mere analgesia, comprehensive patient care for CMP requires acknowledgment of the complex and multifactorial nature of pain and its foundational elements. Embracing an integrative treatment model allows healthcare practitioners to promise better patient prognoses, enriched life quality, and a decrease in the sustained healthcare costs associated with CMP.

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA.

METHOD

Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored.

RESULTS

We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations.

CONCLUSION

There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

Minimal clinical datasets for spine-related musculoskeletal disorders in primary and outpatient care settings: a scoping review

OBJECTIVES

Effective measurement and monitoring of health status in patients with spine-related musculoskeletal (MSK) disorders are essential for providing appropriate care and improving outcomes. Minimal clinical datasets are standardized sets of key data elements and patient-centered outcomes that can be measured and recorded during routine clinical care. Our scoping review aimed to identify and map current evidence on minimal clinical datasets for measuring and monitoring health status in patients with spine-related MSK disorders in primary and outpatient healthcare settings.

STUDY DESIGN AND SETTING

We followed the JBI (formerly Joanna Briggs Institute) methodology for scoping reviews. MEDLINE, CINAHL, Cochrane Library, Index to Chiropractic Literature, MANTIS, ProQuest Dissertations and Theses Global, and medRxiv preprint repository were searched from database inception to August 1, 2021. Two reviewers independently screened titles and abstracts, full-text articles, and charted the evidence. Findings were synthesized and summarized descriptively.

RESULTS

After screening 5,583 citations and 301 full-text articles, 104 studies about 32 individual minimal clinical datasets were included. Most minimal clinical datasets were developed for patient populations with spine-involving inflammatory arthritis, nonspecific or degenerative spinal pain, and MSK disorders in general. The minimal clinical datasets varied substantially in terms of the author-reported time-to-complete (1-48 minutes) and the number of items (5-100 items). Fifty percent of the datasets involved healthcare professionals in their development process, and only 28% involved patients. Health domain items were most frequently linked to the components of activities and participation (43.9%) and body functions (28.6%), according to the International Classification of Functioning, Disability, and Health. There is no standardized definition of minimal clinical datasets to measure and monitor health status of patients with spine-related MSK disorders in routine clinical practice. Common core elements identified were practicality, feasibility in a busy routine practice, time efficiency, and the capability to be used across different healthcare settings.

CONCLUSION

Due to the absence of a standard definition for minimal clinical datasets for patients with spine-related MSK disorders, there is a lack of consistency in the selection of key data elements and patient-centered outcomes that should be included. More research on the implementation and feasibility of minimal clinical datasets in routine care settings is warranted and needed. It is essential to involve all relevant partners in the development process of minimal clinical datasets to ensure successful implementation and adoption in routine primary care.

How do Employees with Chronic Musculoskeletal Disorders Experience the Management of Their Condition in the Workplace? A Metasynthesis

This metasynthesis contributes to an understanding of the experiences, perceptions, and attitudes of employees on managing chronic musculoskeletal disorders (CMSDs) at work. Many studies in this field are concerned with prevention or return-to-work (RTW) programmes. However, the purpose of this review was to synthesise evidence that only focuses on the employees' management of their CMSDs at work. The SPIDER framework was used to structure the question "How do employees with CMSDs experience the management of their condition in the workplace"? The literature search focused on articles published between 2011 and 2021, and the search was conducted using the following databases: MEDLINE, SCOPUS, CINAHL, AMED, PsycINFO. The review identified nine articles that explored employees' experiences of managing CMSDs at work. Thematic synthesis was used to create analytic themes which provided a more in-depth discussion of these experiences. The identified themes were: 'employees actively seek ways to manage their conditions', 'influence of work environment on employees with CMSDs' and 'optimising the relationship between employees and managers. This metasynthesis suggests that the ability to negotiate workplace support and manage CMSDs at work is influenced by the cultural and social environment of the organisation. Effective communication, care and trust between the employee is needed. The review also illustrated the need for healthcare professionals to provide support to employees at work.

'It's about time'. Dissemination and evaluation of a global health systems strengthening roadmap for musculoskeletal health - insights and future directions

Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions-the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A 'roadmap' for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents 'agreed' or 'strongly agreed' the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated.

Barriers to healthcare access in patients with chronic pain or potential migraine in Japan: a cross-sectional internet survey

Purpose

Chronic pain and migraines often go untreated despite patient- and economic-related burdens (e.g., impaired quality of life and productivity). Understanding the reasons for non-treatment is important to enable interventions aimed at improving care-seeking behaviors. However, reports on disease-specific justifications for nontreatment in Japan are limited. We aimed to determine the barriers to healthcare access in untreated patients with chronic pain or migraines.

Patients and methods

This was a non-interventional, cross-sectional, internet questionnaire survey of patients with chronic pain or migraines. The primary endpoint was to identify the reasons for untreated chronic pain or migraines. Secondary endpoints included factors associated with healthcare access, including patient background, patient-reported outcomes, and awareness of generic or authorized generic drugs (AG).

Results

We surveyed 1,089 patients with chronic pain [605 (55.6%) untreated] and 932 patients with migraines [695 (74.6%) untreated] in 2021. The main reasons for not seeking treatment for chronic pain was "my pain is tolerable" and for migraine, "I can manage my pain with over-the-counter drugs." Background factors significantly associated with untreated chronic pain were younger age, less time required to access the nearest medical institution, less pain, higher activities of daily living (ADL) scores, and lower awareness of generic drugs and AG. Among patients with migraine, notable characteristics included being female, having shorter travel times to the nearest medical facility, residing in municipalities with populations under 50,000, experiencing moderate to severe pain, having higher ADL scores, and displaying lower awareness of AG. The AG awareness rate was 2-fold higher in treated patients than in untreated patients.

Conclusion

Educating patients regarding the risks associated with pain and its underlying causes, availability of inexpensive treatment options, and location of appropriate treatment facilities may increase treatment rates.

Untreated osteoporosis and higher FRAX as risk factors for tooth loss: a 5-year prospective study

INTRODUCTION

Studies have shown that an impaired bone condition, represented by osteoporosis and increased fracture risk, may potentially aggravate periodontal disease and, consequently, the risk of tooth loss. This 5-year prospective study aimed to investigate whether systemic bone condition represents risk factor for tooth loss due to periodontal disease amongst elderly women.

MATERIAL AND METHODS

Seventy-four participants, aged ≥ 65 years, who attended the 5-years recall for periodontal evaluation were involved. Baseline exposures were osteoporosis and fracture risk probabilities (FRAX). Women were grouped according to bone mineral density (BMD) and years of bone treatment for osteoporosis. The primary outcome at a 5-year follow-up was the number of tooth loss due to periodontal disease. Periodontitis staging and grading, and causes of tooth loss were recorded.

RESULTS

The multivariate Poisson regression models showed that women with untreated/shortly treated osteoporosis were 4 times more likely to present higher number of tooth loss due to periodontal disease than those with normal BMD or treated for ≥ 3 years (risk ratio (RR) = 4.00, 95% CI 1.40-11.27). Higher FRAX was also linked to tooth loss (RR = 1.25, 95% CI 1.02-1.53). Receiver-operating characteristic (ROC) curve suggested that women with history of ≥ 1 tooth losses have higher chances of worse major FRAX (sensitivity = 72.2%; specificity = 72.2%).

CONCLUSION

In this 5-year study, higher FRAX and untreated osteoporosis were risk factors for tooth loss. Women with normal BMD or treated for osteoporosis for ≥ 3 years did not show increased risk. Management of skeletal conditions should be emphasized with periodontal care for the prevention of tooth loss in elderly women.

From Local Action to Global Policy: A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development

BACKGROUND

Global policy to guide action on musculoskeletal (MSK) health is in a nascent phase. Lagging behind other non-communicable diseases (NCDs) there is currently little global policy to assist governments to develop national approaches to MSK health. Considering the importance of comparison and learning for global policy development, we aimed to perform a comparative analysis of national MSK policies to identify areas of innovation and draw common themes and principles that could guide MSK health policy.

METHODS

Multi-modal search strategy incorporating a systematic online search targeted at the 30 most populated nations; a call to networked experts; a specified question in a related eDelphi questionnaire; and snowballing methods. Extracted data were organised using an a priori framework adapted from the World Health Organization (WHO) Building Blocks and further inductive coding. Subsequently, texts were open coded and thematically analysed to derive specific sub-themes and principles underlying texts within each theme, serving as abstracted, transferable concepts for future global policy.

RESULTS

The search yielded 165 documents with 41 retained after removal of duplicates and exclusions. Only three documents were comprehensive national strategies addressing MSK health. The most common conditions addressed in the documents were pain (non-cancer), low back pain, occupational health, inflammatory conditions, and osteoarthritis. Across eight categories, we derived 47 sub-themes with transferable principles that could guide global policy for: service delivery; workforce; medicines and technologies; financing; data and information systems; leadership and governance; citizens, consumers and communities; and research and innovation.

CONCLUSION

There are few examples of national strategic policy to address MSK health; however, many countries are moving towards this by documenting the burden of disease and developing policies for MSK services. This review found a breadth of principles that can add to this existing work and may be adopted to develop comprehensive system-wide MSK health approaches at national and global levels.

Self-reported attitudes, skills and use of evidence-based practice among Swiss chiropractors: a national survey

STUDY OBJECTIVES

The high burden of disease associated with musculoskeletal disorders severely impacts patients' well-being. As primary care providers, Swiss chiropractors ought to contribute towards identifying and using effective treatment strategies. An established approach is the full integration of evidence-based practice (EBP). This study aimed to investigate the attitudes, skills and use of EBP among Swiss chiropractors, as well as investigating potential facilitators and barriers for its adoption.

METHODS AND MATERIAL

All 329 members of the Swiss Association of Chiropractic (ChiroSuisse) were invited in March 2021 to participate in this cross-sectional survey. Data were acquired anonymously online, using the Evidence-Based practice Attitude and utilization SurvEy (EBASE). The survey encompassed 55 questions measuring attitudes (n = 8, response range 1-5; total score range of 8-40), skills (n = 13, response range 1-5; total score range of range of 13-65) and use of EBP (n = 6, response range 0-4; total score range of 0-24).

RESULTS

228 (69.3%) chiropractors returned complete EBASE questionnaires. This sample was representative of all ChiroSuisse members with respect to gender, age groups and proportion of chiropractic residents. Respondents generally held positive attitudes towards EBP, as indicated by the high mean (31.2) and median (31) attitude sub-score (range 11-40). Self-reported skills had a mean sub-score of 40.2 and median of 40 (range 13-65). Knowledge about EBP-based clinical practice had been primarily obtained in chiropractic under- or postgraduate education (33.8% and 26.3%, respectively). Use of EBP achieved a lower sub-score, with mean and median values of 7.4 and 6, respectively (range 0-24). The most commonly identified barriers preventing EBP uptake were lack of time (67.9%) and lack of clinical evidence in chiropractic/manual therapy-related health fields (45.1%).

CONCLUSION

Swiss chiropractors held favourable attitudes and reported moderate to moderate-high skill levels in EBP. Nevertheless, similar to chiropractors in other countries, the self-reported use of EBP was relatively low, with lack of time and lack of clinical evidence being the most named barriers.

The prevalence and management of chronic pain in the Chinese population: findings from the China Pain Health Index (2020)

BACKGROUND

Chronic pain is a common disease; about 20% of people worldwide suffer from it. While compared with the research on the prevalence and management of chronic pain in developed countries, there is a relative lack of research in this field in China. This research aims to construct the China Pain Health Index (CPHI) to evaluate the current status of the prevalence and management of chronic pain in the Chinese population.

METHODS

The dimensions and indicators of CPHI were determined through literature review, Delphi method, and analytical hierarchy process model, and the original values ​​of relevant indicators were obtained by collecting multi-source data. National and sub-provincial scores of CPHI (2020) were calculated by co-directional transformation, standardization, percentage transformation of the aggregate, and weighted summation.

RESULTS

The highest CPHI score in 2020 is Beijing, and the lowest is Tibet. The top five provinces are Beijing (67.64 points), Shanghai (67.04 points), Zhejiang (65.74 points), Shandong (61.16 points), and Tianjin (59.99 points). The last five provinces are Tibet (33.10 points), Ningxia (37.24 points), Guizhou (39.85 points), Xinjiang (39.92 points), and Hainan (40.38 points). The prevalence of chronic pain is severe in Heilongjiang, Chongqing, Guizhou, Sichuan, and Fujian. Guizhou, Hainan, Xinjiang, Beijing, and Guangdong display a high burden of chronic pain. The five provinces of Guangdong, Shanghai, Beijing, Jiangsu, and Zhejiang have better treatment for chronic pain, while Tibet, Qinghai, Jilin, Ningxia, and Xinjiang have a lower quality of treatment. Beijing, Shanghai, Qinghai, Guangxi, and Hunan have relatively good development of chronic pain disciplines, while Tibet, Sichuan, Inner Mongolia, Hebei, and Guizhou are relatively poor.

CONCLUSION

The economically developed provinces in China have higher CPHI scores, while economically underdeveloped areas have lower scores. The current pain diagnosis and treatment situation in economically developed regions is relatively good, while that in financially underdeveloped areas is rather poor. According to the variations in the prevalence and management of chronic pain among populations in different provinces in China, it is necessary to implement chronic pain intervention measures adapted to local conditions.

The Effect of an App-Based Home Exercise Program on Self-reported Pain Intensity in Unspecific and Degenerative Back Pain: Pragmatic Open-label Randomized Controlled Trial

BACKGROUND

The recommended first-line treatment for unspecific and degenerative back pain consists of movement exercises and patient education.

OBJECTIVE

Using a pragmatic, randomized controlled trial, we evaluated the effectiveness of a digital home exercise program on self-reported pain intensity compared with the standard of care for physiotherapy.

METHODS

Participant recruitment was based on newspaper advertisements and a consecutive on-site assessment for eligibility and enrollment. Participants with unspecific and degenerative back pain aged ≥18 years were randomly assigned in a 1:1 ratio to receive a 12-week stand-alone digital home exercise program or physiotherapy. The digital home exercise program included 4 exercises daily, while physiotherapy included 6 to 12 sessions, depending on the severity of symptoms. The primary outcome was pain, which was assessed using a verbal numerical rating scale. The clinical relevance of pain reduction was assessed using the following thresholds: improvement of at least 1.4 points on the verbal numerical rating scale and a pain reduction of at least 30%.

RESULTS

During the study period, 108 participants were assigned to the intervention group and 105 participants to the control group. The mean difference in pain scores between the 2 groups at 12 weeks was -2.44 (95% CI -2.92 to -1.95; P<.01) in favor of the intervention group. The group receiving the digital therapeutic achieved a clinically relevant reduction in pain over the course of the study (baseline vs 12 weeks), with a mean change of -3.35 (SD 2.05) score points or -53.1% (SD 29.5). By contrast, this change did not reach clinical relevance in the control group (mean -0.91, SD 1.5; -14.6%, SD 25.3). Retention rates of 89.9% in the intervention group and 97.3% in the control group were maintained throughout the study.

CONCLUSIONS

The use of the app-based home exercise program led to a significant and clinically relevant reduction in pain intensity throughout the 12-week duration of the program. The intervention studied showed superior improvement in self-reported pain intensity when compared with the standard of care. Given the great demand for standard physiotherapy for unspecific and degenerative back pain, digital therapeutics are evolving into a suitable therapeutic option that can overcome the limitations of access and availability of conventional modes of health care delivery into this spectrum of indications. However, further independent evaluations are required to support the growing body of evidence on the effectiveness of digital therapeutics in real-world care settings.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022781; https://tinyurl.com/hpdraa89.

One size does not fit all: Participants' experiences of the selfBACK app to support self-management of low back pain-a qualitative interview study

BACKGROUND

Low back pain (LBP) is one of the most common reasons for disability globally. Digital interventions are a promising means of supporting people to self-manage LBP, but implementation of digital interventions has been suboptimal. An artificial intelligence-driven app, selfBACK, was developed to support self-management of LBP as an adjunct to usual care. To better understand the process of implementation from a participant perspective, we qualitatively explored factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and the self-perceived effects, acceptability, and satisfaction with the selfBACK app.

METHODS

Using a qualitative interview study and an analytic framework approach underpinned by Normalization Process Theory (NPT), we investigated the experiences of patients who participated in the selfBACK randomized controlled trial (RCT). Interviews focused on the motivation to participate in the RCT, experiences of using the selfBACK app, and views about future intended use and potential of using digital health interventions for self-management of LBP. Participants were purposively sampled to represent diversity in age, sex, and implementation reflected by a proxy measure of number of app-generated self-management plans during the first three months of RCT participation.

RESULTS

Twenty-six participants aged 21-78, eleven females and fifteen men, with two to fourteen self-management plans, were interviewed between August 2019 and April 2020. A broad range of factors influencing implementation of selfBACK within all constructs of NPT were identified. Key facilitating factors were preferences and beliefs favoring self-management, a friendly, motivational, and reassuring supporter, tailoring and personalization, convenience and ease of use, trustworthiness, perceiving benefits, and tracking achievements. Key impeding factors were preferences and beliefs not favoring self-management, functionality issues, suboptimal tailoring and personalization, insufficient time or conflicting life circumstances, not perceiving benefits, and insufficient involvement of health care practitioners. Self-perceived effects on pain and health, behavior/attitude, and gaining useful knowledge varied by participant.

CONCLUSIONS

The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions using digital health tools.

Recent advances in enzyme-related biomaterials for arthritis treatment

Arthritis is a group of highly prevalent joint disorders, and osteoarthritis (OA) and rheumatoid arthritis are the two most common types. The high prevalence of arthritis causes severe burdens on individuals, society and the economy. Currently, the primary treatment of arthritis is to relieve symptoms, but the development of arthritis cannot be effectively prevented. Studies have revealed that the disrupted balance of enzymes determines the pathological changes in arthritis. In particular, the increased levels of matrix metalloproteinases and the decreased expression of endogenous antioxidant enzymes promote the progression of arthritis. New therapeutic strategies have been developed based on the expression characteristics of these enzymes. Biomaterials have been designed that are responsive when the destructive enzymes MMPs are increased or have the activities of the antioxidant enzymes that play a protective role in arthritis. Here, we summarize recent studies on biomaterials associated with MMPs and antioxidant enzymes involved in the pathological process of arthritis. These enzyme-related biomaterials have been shown to be beneficial for arthritis treatment, but there are still some problems that need to be solved to improve efficacy, especially penetrating the deeper layer of articular cartilage and targeting osteoclasts in subchondral bone. In conclusion, enzyme-related nano-therapy is challenging and promising for arthritis treatment.

Management of Chronic Musculoskeletal Disorders in the Workplace from the Perspective of Older Employees: A Mixed Methods Research Study

(1) Background: This mixed methods research (MMR) study explored older employees’ experiences of chronic musculoskeletal disorders (CMSDs) in relation to their employment, their perspectives on managing these conditions in the workplace and the strategies used to facilitate and maintain their roles and responsibilities. The services offered to them were also identified. (2) Methods: A mixed methods exploratory sequential design was implemented. In the first qualitative phase, 16 semi-structured interviews gathered in-depth information from older employees. The findings informed the development of an online questionnaire in the survey phase, which was administered to older employees (N = 107). Both sets of findings were then integrated using a narrative joint display. (3) Results: The phenomena of presenteeism and leaveism were important components of employees’ strategies for managing their condition. The integrated findings highlighted the roles of employers, managers and social support in encouraging disclosure and supporting the management of CMSDs. The results also emphasised how self-management and professional health services are crucial for sustaining employability. (4) Conclusions: Current challenges call for employers to identify effective ways to support the ageing workforce and invest in training opportunities for managers and collaborative opportunities with healthcare professionals and other stakeholders. A flexible, empathetic and resourceful work environment is optimal for supporting sustained employability for an ageing workforce.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Unraveling Negative Expectations and Nocebo-Related Effects in Musculoskeletal Pain

This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal (MSK) pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence (i.e., belief-lifting the arm leads to permanent tendon damage; evidence-after the patient lifts the arm no tendon damage occurs). While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, according to which the level of precision of the priors (i.e., expectations) is the determinant factor accounting for the extent of priors' updating (i.e., we merge the two frameworks, suggesting that highly precise prior can lead to cognitive immunization responses). Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations (i.e., positive or negative and the level of their precision).

Quantifying the Employer Burden of Persistent Musculoskeletal Pain at a Large Employer in the United Kingdom: A Non-interventional, Retrospective Study of Rolls-Royce Employee Data

OBJECTIVE

To quantify the burden of work-relevant persistent musculoskeletal (MSK) pain to a large UK employer.

METHODS

A retrospective, longitudinal, analytical cohort study using linked Rolls-Royce data systems. Cases were employees with a MSK-related referral to occupational health; controls were age-, sex-, and job role-matched employees without such a referral. Outcomes were compared during 12 months' follow-up.

RESULTS

Overall, 2382 matched case-control pairs were identified (mean age: 46 y; 82% male). Cases took 39,200 MSK-related sickness absence days in total (equating to £50 million in sickness absence costs). Cases took significantly more all-cause sickness absence days than controls (82,341 [£106 million] versus 19,628 [£26 million]; P < 0.0001).

CONCLUSIONS

Despite access to extensive occupational health services, the burden of work-relevant persistent MSK pain remains high in Rolls-Royce. There is a clear need to better understand how to effectively reduce this burden.

A Comprehensive Survey on Bone Segmentation Techniques in Knee Osteoarthritis Research: From Conventional Methods to Deep Learning

Knee osteoarthritis (KOA) is a degenerative joint disease, which significantly affects middle-aged and elderly people. The majority of KOA is primarily based on hyaline cartilage change, according to medical images. However, technical bottlenecks such as noise, artifacts, and modality pose enormous challenges for an objective and efficient early diagnosis. Therefore, the correct prediction of arthritis is an essential step for effective diagnosis and the prevention of acute arthritis, where early diagnosis and treatment can assist to reduce the progression of KOA. However, predicting the development of KOA is a difficult and urgent problem that, if addressed, could accelerate the development of disease-modifying drugs, in turn helping to avoid millions of total joint replacement procedures each year. In knee joint research and clinical practice there are segmentation approaches that play a significant role in KOA diagnosis and categorization. In this paper, we seek to give an in-depth understanding of a wide range of the most recent methodologies for knee articular bone segmentation; segmentation methods allow the estimation of articular cartilage loss rate, which is utilized in clinical practice for assessing the disease progression and morphological change, ranging from traditional techniques to deep learning (DL)-based techniques. Moreover, the purpose of this work is to give researchers a general review of the currently available methodologies in the area. Therefore, it will help researchers who want to conduct research in the field of KOA, as well as highlight deficiencies and potential considerations in application in clinical practice. Finally, we highlight the diagnostic value of deep learning for future computer-aided diagnostic applications to complete this review.

Effectiveness of App-Delivered, Tailored Self-management Support for Adults With Lower Back Pain-Related Disability: A selfBACK Randomized Clinical Trial

IMPORTANCE

Lower back pain (LBP) is a prevalent and challenging condition in primary care. The effectiveness of an individually tailored self-management support tool delivered via a smartphone app has not been rigorously tested.

OBJECTIVE

To investigate the effectiveness of selfBACK, an evidence-based, individually tailored self-management support system delivered through an app as an adjunct to usual care for adults with LBP-related disability.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial with an intention-to-treat data analysis enrolled eligible individuals who sought care for LBP in a primary care or an outpatient spine clinic in Denmark and Norway from March 8 to December 14, 2019. Participants were 18 years or older, had nonspecific LBP, scored 6 points or higher on the Roland-Morris Disability Questionnaire (RMDQ), and had a smartphone and access to email.

INTERVENTIONS

The selfBACK app provided weekly recommendations for physical activity, strength and flexibility exercises, and daily educational messages. Self-management recommendations were tailored to participant characteristics and symptoms. Usual care included advice or treatment offered to participants by their clinician.

MAIN OUTCOMES AND MEASURES

Primary outcome was the mean difference in RMDQ scores between the intervention group and control group at 3 months. Secondary outcomes included average and worst LBP intensity levels in the preceding week as measured on the numerical rating scale, ability to cope as assessed with the Pain Self-Efficacy Questionnaire, fear-avoidance belief as assessed by the Fear-Avoidance Beliefs Questionnaire, cognitive and emotional representations of illness as assessed by the Brief Illness Perception Questionnaire, health-related quality of life as assessed by the EuroQol-5 Dimension questionnaire, physical activity level as assessed by the Saltin-Grimby Physical Activity Level Scale, and overall improvement as assessed by the Global Perceived Effect scale. Outcomes were measured at baseline, 6 weeks, 3 months, 6 months, and 9 months.

RESULTS

A total of 461 participants were included in the analysis; the population had a mean [SD] age of 47.5 [14.7] years and included 255 women (55%). Of these participants, 232 were randomized to the intervention group and 229 to the control group. By the 3-month follow-up, 399 participants (87%) had completed the trial. The adjusted mean difference in RMDQ score between the 2 groups at 3 months was 0.79 (95% CI, 0.06-1.51; P = .03), favoring the selfBACK intervention. The percentage of participants who reported a score improvement of at least 4 points on the RMDQ was 52% in the intervention group vs 39% in the control group (adjusted odds ratio, 1.76; 95% CI, 1.15-2.70; P = .01).

CONCLUSIONS AND RELEVANCE

Among adults who sought care for LBP in a primary care or an outpatient spine clinic, those who used the selfBACK system as an adjunct to usual care had reduced pain-related disability at 3 months. The improvement in pain-related disability was small and of uncertain clinical significance. Process evaluation may provide insights into refining the selfBACK app to increase its effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03798288.

Developing a core outcome set for community and primary care musculoskeletal services: A consensus approach

BACKGROUND

At present there is no core outcome set (COS) for use in community and primary care Musculoskeletal (MSK) services across the UK. Services are therefore collecting different MSK outcomes and metrics in different ways and at different times. Standardising MSK data collection is essential in order for fair and impactful benchmarking to improve the quality of care delivered to the millions of patients presenting each year with MSK disorders.

OBJECTIVE

To gain consensus on a proposed set of metrics that could be used to develop a COS for use in routine practice in community and primary care MSK services in the UK and to make recommendations to inform a future national MSK audit.

METHODS

A consensus process involving researchers, healthcare professionals and patients. Previous research generated an initial list of proposed metrics. This proposal was then taken to wider stakeholder consensus via an online survey designed for both healthcare professionals and MSK service users.

RESULTS

199 respondents completed the survey, 166 healthcare professionals and 33 service users (25/33 eligible to answer all items within the survey). Metrics that reached strong consensus were; age, pain site, comorbidities, duration of symptoms, work status, work absence, work absence duration. No Patient Reported Outcome Measures (PROMs) met strong consensus and all Patient Reported Experience Measures (PREMs) other than timeliness/convenience met strong consensus criteria.

CONCLUSION

7 baseline factors and 9 PREM domains reached strong consensus. The MSK-HQ PROM was the highest rated outcome measure so was also recommended for inclusion in an MSK COS.

Staying at work with musculoskeletal pain: What supporting resources do people need?

INTRODUCTION

Maintaining productive employment can be challenging for people with ongoing low back pain (LBP) or neck pain (NP) due to pain, function and participation sequelae. Resources and information to support them staying at work may be beneficial, although preferences for the nature and accessibility of resources remain uncertain. The current study aimed to explore the work experiences and information-seeking behaviours of employed individuals with ongoing LBP or NP, to support them in staying at work.

METHOD

Semi-structured interviews were undertaken with 40 participants currently employed with ongoing LBP or NP. The interview schedule covered participants' experience of managing their LBP or NP at work, resources sought to assist with finding or maintaining employment, and where they accessed these resources. Interviews were recorded and analysed using thematic analysis.

RESULTS

Participants were employed in a wide range of job types and most reported a decrease in productivity. Five key themes were identified: (1) the meaning of work, (2) to disclose or not, (3) information seeking, (4) gaps in resources, (5) trusted sources. Work was highly valued by participants, despite the challenges in maintaining employment with ongoing LBP or NP. To support staying at work a range of information was sought by participants, but challenges in accessing reputable resources and trusting the sources were identified as key issues.

CONCLUSION

Opportunities exist for easily accessible, multi-level information from trustworthy sources targeted at the employer organisations, individuals and clinicians to support people in staying at work with ongoing LBP or NP.

Association between joint diseases and common mental disorders in women at ages related to menopause: Data from the São Paulo City Health Survey, SP, Brazil

OBJECTIVES

To investigate the association between joint diseases (JD) and common mental disorders (CMD) in women at ages related to menopause.

STUDY DESIGN

Cross-sectional, population-based study (São Paulo City Health Survey, SP, Brazil). The sample was composed of 1191 women, 40 years and older.

MAIN PARAMETERS INVESTIGATED

Dependent variable (outcome): Presence of CMD, investigated by the Self Reporting Questionnaire-20 (SRQ-20).

INDEPENDENT VARIABLES

Presence of JD; other self-reported chronic conditions different from JD (OCC); age categories (40-45, 46-50, 51-55, 56-60, 61+ years old); Adjusting variables: years of formal education and ethnicity (skin color), used as proxies of socioeconomic status. The associations were investigated using simple and multiple logistic regression models.

MAIN RESULTS

The prevalence of CMD was 30.4%, and JD was 21.4%. Considering only the women presenting CMD, the prevalence of JD was 31.6%. The final regression model showed an independent association between JD and CMD (OR = 1.998; p < 0.001), age between 56 and 60 years (OR = 0.542; p = 0.018), and having three OCC (OR = 2.696; p = 0.027).

CONCLUSIONS

Our data showed that JD in women of the ages related to menopause was significantly and independently associated with CMD. Interestingly, the 56 to 60 years' age interval showed a very particular feature, with opposite association's direction, which demands further investigations.

The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants

BACKGROUND

Musculoskeletal (MSK) conditions, MSK pain and MSK injury/trauma are the largest contributors to the global burden of disability, yet global guidance to arrest the rising disability burden is lacking. We aimed to explore contemporary context, challenges and opportunities at a global level and relevant to health systems strengthening for MSK health, as identified by international key informants (KIs) to inform a global MSK health strategic response.

METHODS

An in-depth qualitative study was undertaken with international KIs, purposively sampled across high-income and low and middle-income countries (LMICs). KIs identified as representatives of peak global and international organisations (clinical/professional, advocacy, national government and the World Health Organization), thought leaders, and people with lived experience in advocacy roles. Verbatim transcripts of individual semi-structured interviews were analysed inductively using a grounded theory method. Data were organised into categories describing 1) contemporary context; 2) goals; 3) guiding principles; 4) accelerators for action; and 5) strategic priority areas (pillars), to build a data-driven logic model. Here, we report on categories 1-4 of the logic model.

RESULTS

Thirty-one KIs from 20 countries (40% LMICs) affiliated with 25 organisations participated. Six themes described contemporary context (category 1): 1) MSK health is afforded relatively lower priority status compared with other health conditions and is poorly legitimised; 2) improving MSK health is more than just healthcare; 3) global guidance for country-level system strengthening is needed; 4) impact of COVID-19 on MSK health; 5) multiple inequities associated with MSK health; and 6) complexity in health service delivery for MSK health. Five guiding principles (category 3) focussed on adaptability; inclusiveness through co-design; prevention and reducing disability; a lifecourse approach; and equity and value-based care. Goals (category 2) and seven accelerators for action (category 4) were also derived.

CONCLUSION

KIs strongly supported the creation of an adaptable global strategy to catalyse and steward country-level health systems strengthening responses for MSK health. The data-driven logic model provides a blueprint for global agencies and countries to initiate appropriate whole-of-health system reforms to improve population-level prevention and management of MSK health. Contextual considerations about MSK health and accelerators for action should be considered in reform activities.

This is the day your life must surely change : Prioritising behavioural change in musculoskeletal practice

Behavioural change is the modification or transformation of behaviour. Health behaviour has been defined as, 'any activity undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing' (Bennell et al., 2019 [1]). For a smoker it is acting on the decision to stop or reduce the number of cigarettes smoked, for someone with a higher than ideal body mass index, it is acting to reduce weight and for someone who isn't achieving ideal levels of exercise (Briggs et al., 2020 [2]) it is the decision and action to increase metabolic activity. With increased understanding of the importance of self-management and impact of lifestyle, clinicians supporting people presenting with musculoskeletal symptoms have recognized that behavioural change is an essential component of the care we need to prioritize. It is about sharing the benefits of lifestyle choices that promote health, discussing how to introduce and maintain them, and supporting people through their journey of change, so the change becomes the new normal. Behavioural change science assumes that (i) morbidity and mortality are due in part to certain behaviours and (ii) these behaviours are modifiable. The aim of this debate article is to discuss reasons why clinicians must include long term behavioural change into their management plan and methods they may use to facilitate the change ensuring recipients are empowered to act and make today the day their 'lives will surely change'.

Trends in long-term opioid prescriptions for musculoskeletal conditions in Australian general practice: a national longitudinal study using MedicineInsight, 2012-2018

OBJECTIVE

Describe trends and patterns in long-term opioid prescriptions among adults with musculoskeletal conditions (MSK).

DESIGN

Interrupted time-series analysis based on an open cohort study.

SETTING

A representative sample of 402 Australian general practices contributing data to the MedicineInsight database.

PARTICIPANTS

811 174 patients aged 18+ years with an MSK diagnosis and three or more consultations in any two consecutive years between 2012 and 2018. Males represented 44.5% of the sample, 28.4% were 65+ years and 1.9% were Aboriginal or Torres Strait Islanders.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual prevalence and cumulative incidence (%) of long-term opioid prescribing (3+ prescriptions in 90 days) among patients with an MSK. Average duration of these episodes in each year between 2012 and 2018.

RESULTS

The prevalence of long-term opioid prescribing increased from 5.5% (95% CI 5.2 to 5.8) in 2012 to 9.1% (95% CI 8.8 to 9.7) in 2018 (annual change OR 1.09, 95% CI 1.08 to 1.09), but a slightly lower incidence was observed in 2018 (3.0% vs 3.6%-3.8% in other years; annual change OR 0.99, 95% CI 0.98 to 0.99). The incidence was between 37% and 52% higher among practices located in rural Australia or lower socioeconomic areas. Individual risk factors included increasing age (3.4 times higher among those aged 80+ years than the 18-34 years group in 2012, increasing to 4.8 times higher in 2018), identifying as Aboriginal or Torres Strait Islander (1.7-1.9 higher incidence than their peers), or living in disadvantaged areas (36%-57% more likely than among those living in wealthiest areas). Long-term opioid prescriptions lasted in average 287-301 days between 2012 and 2016, reducing to 229 days in 2017 and 140 days in 2018. A longer duration was observed in practices from more disadvantaged areas and females in all years, except in 2018.

CONCLUSIONS

The continued rise in the prevalence of long-term opioid prescribing is of concern, despite a recent reduction in the incidence and duration of opioid management.

Clinical and cost-effectiveness of an online-delivered group-based pain management programme in improving pain-related disability for people with persistent pain-protocol for a non-inferiority randomised controlled trial (iSelf-help trial)

INTRODUCTION

Persistent non-cancer pain affects one in five adults and is more common in Māori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability.

METHODS AND ANALYSIS

Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA).

ETHICS AND DISSEMINATION

The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent.

TRIAL REGISTRATION NUMBER

ACTRN 12619000771156.

Musculoskeletal health - The case for action

Musculoskeletal health is critical for human function, enabling mobility, dexterity and the ability to work and actively participate in all aspects of life. It is essential for maintaining economic, social and functional independence as well as human capital across the life course. Action is needed and the Global Alliance for Musculoskeletal Health (G-MUSC) is working with the entire musculoskeletal community to develop a global consensus on the important components of a global strategy. This will serve to influence and accelerate the priorities and actions of countries and international agencies such as the WHO. This issue aims to provide a background for developing such a global strategy for improving musculoskeletal health.