Key components and potential benefits of a comprehensive approach to women's musculoskeletal health

The Quality and Cultural Safety of Online Osteoarthritis Information for Affected Persons and Health Care Professionals: Content Analysis

BACKGROUND

Osteoarthritis is more prevalent and severe among women than among men, but women are less likely to access early diagnosis and first-line management, particularly racialized immigrant women. Previous research advocated for greater access to culturally safe osteoarthritis information for both diverse women and health care professionals. The internet can reduce disparities by facilitating access to health information, but online materials can vary in quality.

OBJECTIVE

This study aimed to assess the quality and cultural safety of online osteoarthritis materials for persons affected by osteoarthritis and health care professionals.

METHODS

Content analysis was used to describe publicly available materials on osteoarthritis first-line management developed by Canadian organizations for affected persons or health care professionals. Searching, screening, and data extraction were performed in triplicate. We identified materials by searching Google, MEDLINE, and references of osteoarthritis-relevant guidelines and policies, and consulting our research team and collaborators. We assessed quality using DISCERN (University of Oxford) and a compiled framework for affected persons and health care professionals. We compiled frameworks to assess cultural safety. We derived an overall score, categorized as low (<50%), moderate (50%-69%), or high (≥70%+) for criteria met.

RESULTS

After screening 176 items and eliminating 129, we included 47 osteoarthritis materials published between 2013 and 2023. Of those, 43 were for persons with osteoarthritis, most were developed by charities (n=31, 72.1%), based on expert advice (n=16, 55.2%), and in the format of booklets (n=15, 34.9%) or text on web pages (n=10, 23.3%). Of those, 23.3% (10/43) low, 46.5% (20/43) moderate, and 30.2% (13/43) high scored quality; and 25.6% (11/43), 48.8% (21/43), and 25.6% (11/43) were rated low, moderate, and high cultural safety, respectively. Of the 47 included osteoarthritis materials, 4 were for health care professionals. They were developed by a consortium (2/4, 50%), a charity (1/4, 25%), and a professional society (1/4, 25%), and largely based on expert advice (3/4, 75%). The format included infographics (3/4, 75%) and text on web pages (1/4, 25%). Of those, 25% (1/4), 25% (1/4), and 50% (2/4) were rated low, moderate, and high quality, respectively; and all were rated low for cultural safety. Quality and cultural safety did not appear to be associated with the characteristics of osteoarthritis materials (eg, type of developer, development method, and format).

CONCLUSIONS

Overall, included osteoarthritis materials for persons with osteoarthritis and health care professionals were of low to moderate quality and cultural safety. These findings reveal the need for further efforts to improve existing or develop new osteoarthritis materials for both affected persons, including ethnoculturally diverse immigrant women, and health care professionals. Further research is needed to assess the quality and cultural safety of osteoarthritis materials developed by organizations outside of Canada and to establish a framework or instrument to assess cultural safety in the osteoarthritis context.

Increased prevalence of lower extremity soft tissue injuries and surgeries in patients with anorexia nervosa and bulimia nervosa

PURPOSE

An abundance of literature exists linking eating disorders and fracture risk. However, no studies, to our knowledge, have investigated the impact of eating disorders on lower extremity soft tissue injury or surgery risk. The purpose of this study was to determine if anorexia nervosa and bulimia nervosa are associated with prevalence of lower extremity soft tissue injuries and surgeries.

METHODS

Patients with anorexia nervosa or bulimia nervosa over 2010-2020 were identified through the International Classification of Diseases (ICD) codes in the PearlDiver Claims Database. Patients were matched by age, gender, comorbidities, record dates, and region to control groups without anorexia or bulimia. Soft tissue injuries were identified through ICD codes, and surgeries were identified through Current Procedural Terminology codes. Differences in relative prevalence were analyzed using chi-square analysis.

RESULTS

Patients with anorexia had a significantly increased prevalence of meniscus tears (RR = 1.57, CI 1.22-2.03, p = 0.001) or deltoid ligament sprains (RR = 1.83, CI 1.10-3.03, p = 0.025), and patients with bulimia had a significantly increased prevalence of meniscus tears (RR = 1.98, CI 1.56-2.51, p < 0.001), medial collateral ligament sprains (RR = 3.07, CI 1.72-5.48, p < 0.001), any cruciate ligament tears (RR = 2.14, CI 1.29-3.53, p = 0.004), unspecified ankle sprains (RR = 1.56, CI 1.22-1.99, p < 0.001), or any ankle ligament sprains (RR = 1.27, CI 1.07-1.52, p = 0.008). Patients with anorexia had a significantly increased prevalence of anterior cruciate ligament reconstructions (RR = 2.83, CI 1.12-7.17, p = 0.037) or any meniscus surgeries (RR = 1.54, CI 1.03-2.29, p = 0.042), and patients with bulimia had a significantly increased prevalence of partial meniscectomies (RR = 1.80, CI 1.26-2.58, p = 0.002) or any meniscus surgeries (RR = 1.83, CI 1.29-2.60, p < 0.001).

CONCLUSIONS

Anorexia and bulimia are associated with increased prevalence of soft tissue injuries and surgeries. Orthopedic surgeons should be aware of this risk, and patients presenting to clinics should be informed of the risks associated with these diagnoses and provided with resources promoting recovery to help prevent further injury or surgery.

Multi-level strategies to improve equitable timely person-centred osteoarthritis care for diverse women: qualitative interviews with women and healthcare professionals

BACKGROUND

Women are more likely to develop osteoarthritis (OA), and have greater OA pain and disability compared with men, but are less likely to receive guideline-recommended management, particularly racialized women. OA care of diverse women, and strategies to improve the quality of their OA care is understudied. The purpose of this study was to explore strategies to overcome barriers of access to OA care for diverse women.

METHODS

We conducted qualitative interviews with key informants and used content analysis to identify themes regarding what constitutes person-centred OA care, barriers of OA care, and strategies to support equitable timely access to person-centred OA care.

RESULTS

We interviewed 27 women who varied by ethno-cultural group (e.g. African or Caribbean Black, Chinese, Filipino, Indian, Pakistani, Caucasian), age, region of Canada, level of education, location of OA and years with OA; and 31 healthcare professionals who varied by profession (e.g. family physician, nurse practitioner, community pharmacist, physio- and occupational therapists, chiropractors, healthcare executives, policy-makers), career stage, region of Canada and type of organization. Participants within and across groups largely agreed on approaches for person-centred OA care across six domains: foster a healing relationship, exchange information, address emotions, manage uncertainty, share decisions and enable self-management. Participants identified 22 barriers of access and 18 strategies to overcome barriers at the patient- (e.g. educational sessions and materials that accommodate cultural norms offered in different languages and formats for persons affected by OA), healthcare professional- (e.g. medical and continuing education on OA and on providing OA care tailored to intersectional factors) and system- (e.g. public health campaigns to raise awareness of OA, and how to prevent and manage it; self-referral to and public funding for therapy, greater number and ethno-cultural diversity of healthcare professionals, healthcare policies that address the needs of diverse women, dedicated inter-professional OA clinics, and a national strategy to coordinate OA care) levels.

CONCLUSIONS

This research contributes to a gap in knowledge of how to optimize OA care for disadvantaged groups including diverse women. Ongoing efforts are needed to examine how best to implement these strategies, which will require multi-sector collaboration and must engage diverse women.

Person-centered care for diverse women: Narrative review of foundational research

Despite advocacy and recommendations to improve health care and health for persons who identify as women, women continue to face inequities in access to and quality of care. Person-centered care for women is one approach that could reduce gendered inequities. We conducted a series of studies to understand what constitutes person-centered care for women and how to achieve it. The overall aim of this article is to highlight the key findings of those studies that can inform policy, practice, and ongoing research. We conducted a narrative review of all studies related to person-centered care for women conducted in our group starting in 2018 over a 5-year period, which was general at the outset, and increasingly focused on racialized immigrant women who constitute a large proportion of the Canadian population. We organized study summaries by research phase: synthesis of person-centered care for women research, exploration of existing person-centered care for women guidance, consultation with key informants, consensus survey of key informants to prioritize strategies to achieve person-centered care for women, and consensus meeting with key informants to prioritize future research. We conducted the reported research in collaboration with an advisory group of diverse women and managers of community agencies. Our research revealed that little prior research had fully established what constitutes person-centered care for women, and in particular, how to achieve it. We also found little acknowledgment of person-centered care for women or strategies to support it in medical curriculum, clinical guidelines, or healthcare policies. We subsequently consulted women who differed by age, ethno-cultural group, health issue, education and geography, and clinicians of different specialties, who offered considerable insight on strategies to support person-centered care for women. Other diverse women, clinicians, healthcare managers, and researchers prioritized issues that warrant future research. We hope that by compiling a summary of our completed research, we draw attention to the need for person-centered care for women and motivate others to pursue it through policy, practice, and research.

Current Concept Review: Inclusion and Analysis of Diverse Study Populations in Orthopaedic Research

As disparities in healthcare access and outcomes have been increasingly identified across medical specialties, the importance of recognizing and understanding the diversity of our patient populations and the influence of individual characteristics such as age, sex, gender, race, and ethnicity on clinical outcomes has been emphasized. Orthopaedic literature has advanced dramatically in the quality and quantity of research generated over the past 25 years, yet a consistent, sustained focus on studying musculoskeletal health in the context of these unique patient-specific variables has not been maintained. The result of this inattention may be the provision of orthopaedic care that is ill-suited for the individual patient whose biologic characteristics, life experiences, and cultural constructs differ from that of the typical research subject. The recent proliferation of meta-analyses-whose intention is to optimize statistical power-likely compounds the problem because improper, inconsistent, or absent categorization of patients in research articles precludes meaningful subgroup analysis. This article describes the current variability in demographic reporting in the orthopaedic literature, highlights the importance of complete, consistent demographic reporting and subgroup analysis, and reviews specific examples of orthopaedic conditions that illustrate how clinical outcomes may be affected by patient-specific variables such as age, sex, gender, race, and ethnicity.

Physiological Factors of Female Runners With and Without Stress Fracture Histories: A Pilot Study

BACKGROUND

Female runners are at increased risk of stress fractures (SFs) compared with men. Literature is lacking with regard to best practice for preventing and treating SFs in women. The purpose of the study was to compare physiological measures and running-related factors between women of various ages and running abilities with and without a history of running-related SFs.

HYPOTHESIS

Women with and without SF histories will differ with regard to medical and menstrual history, bone health, body composition, nutrition, and running history.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

A total of 20 female runners with SF histories were matched based on age and running distance with 20 women without SF histories. Data included medical, menstrual, running, injury, and nutritional histories; blood histology related to nutritional, hormonal, and bone-related risk factors; and bone density, fat, and lean tissue using dual energy x-ray absorptiometry. Paired t tests were used to examine differences between women with and without SF histories, and Spearmen correlations were conducted to examine relationships between physiological factors.

RESULTS

Women with SF histories had lower hip bone mineral density compared with women without SF histories (P < 0.05). SF history was moderately correlated with menstrual changes during increased training times (r = 0.580; P < 0.0001) but was not correlated with any other physiological factor. There was a moderate correlation within the SF group (r = 0.65; P = 0.004) for bone markers for resorption and formation both increasing, indicating increased bone turnover.

CONCLUSION

Female runners with low hip bone mineral density, menstrual changes during peak training, and elevated bone turnover markers may be at increased risk of SF.

CLINICAL RELEVANCE

Female runners need routine screening for risks associated with SF occurrence. As bone mineral density and bone turnover markers are not routinely assessed in this population, important risk factors may be missed.

Sex-Specific Analysis at Two Time Points in Three High-Impact Orthopaedic Sports Medicine Journals

Purpose

To determine how well the orthopaedic sports medicine literature reported sex-specific analysis (SSA) in 2011 and 2016.

Methods

The 3 highest-impact orthopaedic sports medicine subspecialty journals (American Journal of Sports Medicine; Arthroscopy; and Knee Surgery, Sports Traumatology, Arthroscopy) were selected for review. Two independent investigators reviewed all journal issues published during 2 different calendar years (2011 and 2016). All randomized controlled, prospective and retrospective group, and case-control studies were included. Studies were stratified into those that involved SSA, where sex was a variable in a multifactorial statistical model, and those that only reported sex as a demographic characteristic or used sex-matched groups without further analysis.

Results

A total of 960 studies evaluating 3,400,569 patients met criteria and were included in this review. Although 44.4% of the overall study population was female, only 293 (30.5%) studies included patient sex as variable in a multifactorial statistical model. The proportion of studies that performed SSA did not differ between 2011 (29.6%) and 2016 (31.1%; P = .607), although publications from American Journal of Sports Medicine were likely to report SSA (P < .05). Of the 293 studies that reported SSA, 91 (31%) demonstrated a significant difference in outcomes. The most commonly reported differences were in outcomes following anterior cruciate ligament, medial patellofemoral ligament, and posterior cruciate ligament reconstruction; autograft preparation; postoperative use of opiates following arthroscopy; and recovery after sports-related concussions.

Conclusions

Although most sports medicine studies include approximately 50% female and 50% male patients, statistical analysis differentiating the 2 subsets is not routinely performed. Only 30.5% of all studies performed SSA, 31% of which reported a statistically significant difference in the data when comparing outcomes between male and female patients with the same treatment modalities.

Clinical Relevance

The current study demonstrates that the orthopaedic sports medicine subspecialty literature is lacking in reporting SSA, and that there has been minimal improvement over a 5-year time period. In addition, this study highlights the high percentage of significant findings within the studies that performed SSA and underscores the differences in sex-specific injury patterns and treatment outcomes.

Perceptions of risk for stress fractures: A qualitative study of female runners with and without stress fracture histories

OBJECTIVES

To gain insight into perceived factors related to bone health and stress fracture (SF) prevention for female runners and to understand their experiences within the medical community.

DESIGN

Cohort qualitative study.

SETTING

University health system.

PARTICIPANTS

Forty female runners, 20 who had SF histories and 20 age-and-running-distance matched women without SF.

MAIN OUTCOME MEASURES

Women participated in audiotaped qualitative semi-structured interviews. For women with a SF history, questions sought their perspectives on factors that they felt contributed to SF, experiences with the medical community, and changes made post SF. For women without a SF history, questions sought perspectives on factors felt important to perceived running-related bone health.

RESULTS

Six themes emerged; 1) Previous/Recurrent Musculoskeletal Injuries, 2) Activity Patterns and Training Regimens, 3) Nutrition, 4) Prevention and Intervention, 5) Pain, and 6) Mindset. Within these themes, between group differences are characterized by differences in knowledge and/or application of knowledge for health and wellness. Compared to women without SF, women with SF histories increased training load more quickly, had poorer nutrition, performed less cross-training, and kept running despite pain.

CONCLUSIONS

More education is needed for female runners to decrease risks for SF.

Part II: presentation, diagnosis, classification, treatment, and prevention of stress fractures in female athletes

Objectives: Stress fractures (SFx) occur as the result of repetitive loads over short periods of time, which leads to micro-damage of the bone through cortical resorption, ultimately leading to fracture. They are a common injury in female athletes and often cause significant morbidity. The goal of this study is to review the presentation, diagnosis, classification, treatment, and prevention of SFx in female athletes.Results: A thorough history, physical exam, and appropriate imaging can facilitate early diagnosis of stress fracture (SFx) and faster resolution of symptoms with more conservative management. The female athlete triad is an especially important factor that contributes to the increased risk of SFx in females. The continuum of stress injuries ranges from mild microfailure to complete fracture, which has resulted in the development of newer grading schemas through MRI and radiographic findings. Stress fractures are also classified as low- or high-risk according to anatomic location, as blood supply and applied forces at different locations affect the likelihood of fracture propagation, displacement, delayed union, or non-union.Conclusions: The ability to screen for at-risk athletes is paramount in preventing SFx. Recognition and prompt treatment of the female athlete triad requires a multidisciplinary approach in order to restore energy balance, correct menstrual irregularities, and improve bone health. This review provides a basis for understanding how to identify and treat stress fractures, which may allow treating physicians to diagnose this condition earlier and minimize any associated morbidity.

Women's Sports Medicine Programs in the United States: an interdisciplinary approach to the care of girls and women

Objectives: Multiple studies have shown that women are more susceptible to certain musculoskeletal (MSK) injuries than their male counterparts. In response to these identified differences, several institutions have established Women's Sports Medicine Programs (WSMPs). The purpose of this study was to determine the number of WSMPs and explore program characteristics such as geographic location, specialties represented, common conditions treated, program history, and patient population.Methods: An extensive internet search was conducted to identify WSMPs in the United States. The second part of this study involved a 13-question, anonymous, electronic survey that was distributed to the directors of identified WSMPs to gather further data. Descriptive statistics were used to analyze the data.Results: Nineteen WSMPs were identified and the majority have been in existence for 6 to 10 years (44.4%). The survey was delivered to 18 programs and 9 WSMP directors responded (50% response rate). The most commonly reported number of physicians, across all specialties, comprising the core network was two physicians (4 programs, 44.4%). Health care providers with fourteen different areas of specialization were identified across all programs. The most common conditions treated were patellofemoral pain syndrome (33.3%), stress fracture (33.3%), and ACL tear (22.2%). In 5 programs (55.5%), patients < 18 years of age accounted for less than 25% of total patients. Only 2 programs (22.2%) reported that >51% of patients were actively participating in sports.Conclusion: This study demonstrates that nineteen Women's Sports Medicine Programs have been established in the United States. These programs address conditions known to have a higher incidence in the active female population, however the WSMPs are not solely geared towards the treatment of active female athletes. The information provided in this study can serve as a guide for the development of future WSMPs, as well as, future research studies regarding WSMPs.