An Assessment of International Classification of Diseases, 10th Revision, Clinical Modification, Codes Used to Describe Common Pediatric Orthopedic Conditions

The diagnosis coding system for health care providers that is used in the United States recently converted from the International Classification of Diseases, 9th Revision (ICD-9), to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). The authors are unaware of any studies specifically evaluating the utility and specificity of ICD-10-CM codes in the pediatric orthopedic literature. The authors chose 20 diagnoses that are commonly seen in general pediatric orthopedic practice. The study had two goals: (1) to evaluate the adequacy of these codes to describe the diagnoses and (2) to offer advice on the most appropriate code to use when the ideal code does not exist. A list of 20 diagnoses that are commonly seen in general pediatric orthopedic practice were chosen by 2 fellowship-trained pediatric orthopedic surgeons. Each author independently evaluated the appropriate ICD-10-CM code for each diagnosis. The authors came to a consensus regarding whether the codes were adequate and agreed on an appropriate alternate code when the ideal one did not exist. One common condition had no code (accessory navicular), necessitating the recommendation of a nonspecific code. Other seemingly dissimilar conditions were described by the same code (acetabular dysplasia/femoral anteversion, Osgood-Schlatter disease/Blount's disease). Numerous codes lacked specificity, and the option of laterality was not uniform. Compared with the ICD-9, the ICD-10-CM allows more diagnostic options for these 20 common pediatric orthopedic conditions. The authors identified several areas for improvement. Involvement of subspecialty societies could guide future endeavors to improve this new coding system. [Orthopedics. 2020;43(2):e87-e90.].

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity

OBJECTIVE

There are currently no algorithms for early stratification of pediatric musculoskeletal infection (MSKI) severity that are applicable to all types of tissue involvement. In this study, the authors sought to develop a clinical prediction algorithm that accurately stratifies infection severity based on clinical and laboratory data at presentation to the emergency department.

METHODS

An IRB-approved retrospective review was conducted to identify patients aged 0 to 18 who presented to the pediatric emergency department at a tertiary care children's hospital with concern for acute MSKI over a 5-year period (2008 to 2013). Qualifying records were reviewed to obtain clinical and laboratory data and to classify in-hospital outcomes using a 3-tiered severity stratification system. Ordinal regression was used to estimate risk for each outcome. Candidate predictors included age, temperature, respiratory rate, heart rate, C-reactive protein (CRP), and peripheral white blood cell count. We fit fully specified (all predictors) and reduced models (retaining predictors with a P-value ≤0.2). Discriminatory power of the models was assessed using the concordance (c)-index.

RESULTS

Of the 273 identified children, 191 (70%) met inclusion criteria. Median age was 5.8 years. Outcomes included 47 (25%) children with inflammation only, 41 (21%) with local infection, and 103 (54%) with disseminated infection. Both the full and reduced models accurately demonstrated excellent performance (full model c-index 0.83; 95% confidence interval, 0.79-0.88; reduced model 0.83; 95% confidence interval, 0.78-0.87). Model fit was also similar, indicating preference for the reduced model. Variables in this model included CRP, pulse, temperature, and an interaction term for pulse and temperature. The odds of a more severe outcome increased by 30% for every 10 U increase in CRP.

CONCLUSIONS

Clinical and laboratory data obtained in the emergency department may be used to accurately differentiate pediatric MSKI severity. The predictive algorithm in this study stratifies pediatric MSKI severity at presentation irrespective of tissue involvement and anatomic diagnosis. Prospective studies are needed to validate model performance and clinical utility.

LEVEL OF EVIDENCE

Level II-prognostic study.

Scoping review of priority setting of research topics for musculoskeletal conditions

OBJECTIVE

Describe research methods used in priority-setting exercises for musculoskeletal conditions and synthesise the priorities identified.

DESIGN

Scoping review.

SETTING AND POPULATION

Studies that elicited the research priorities of patients/consumers, clinicians, researchers, policy-makers and/or funders for any musculoskeletal condition were included.

METHODS AND ANALYSIS

We searched MEDLINE and EMBASE from inception to November 2017 and the James Lind Alliance top 10 priorities, Cochrane Priority Setting Methods Group, and Cochrane Musculoskeletal and Back Groups review priority lists. The reported methods and research topics/questions identified were extracted, and a descriptive synthesis conducted.

RESULTS

Forty-nine articles fulfilled our inclusion criteria. Methodologies and stakeholders varied widely (26 included a mix of clinicians, consumers and others, 16 included only clinicians, 6 included only consumers or patients and in 1 participants were unclear). Only two (4%) reported any explicit inclusion criteria for priorities. We identified 294 broad research priorities from 37 articles and 246 specific research questions from 17 articles, although only four (24%) of the latter listed questions in an actionable format. Research priorities for osteoarthritis were identified most often (n=7), followed by rheumatoid arthritis (n=4), osteoporosis (n=4) and back pain (n=4). Nearly half of both broad and specific research priorities were focused on treatment interventions (n=116 and 111, respectively), while few were economic (n=8, 2.7% broad and n=1, 0.4% specific), implementation (n=6, 2% broad and n=4, 1.6% specific) or health services and systems research (n=15, 5.1% broad and n=9, 3.7% specific) priorities.

CONCLUSIONS

While many research priority-setting studies in the musculoskeletal field have been performed, methodological limitations and lack of actionable research questions limit their usefulness. Future studies should ensure they conform to good priority-setting practice to ensure that the generated priorities are of maximum value.

PROSPERO REGISTRATION NUMBER

CRD42017059250.

Automatic Musculoskeletal and Neurological Disorder Diagnosis With Relative Joint Displacement From Human Gait

Musculoskeletal and neurological disorders are common devastating companions of ageing, leading to a reduction in quality of life and increased mortality. Gait analysis is a popular method for diagnosing these disorders. However, manually analyzing the motion data is a labor-intensive task, and the quality of the results depends on the experience of the doctors. In this paper, we propose an automatic framework for classifying musculoskeletal and neurological disorders among older people based on 3D motion data. We also propose two new features to capture the relationship between joints across frames, known as 3D Relative Joint Displacement (3DRJDP) and 6D Symmetric Relative Joint Displacement (6DSymRJDP), such that the relative movement between joints can be analyzed. To optimize the classification performance, we adapt feature selection methods to choose an optimal feature set from the raw feature input. Experimental results show that we achieve a classification accuracy of 84.29% using the proposed relative joint features, outperforming existing features that focus on the movement of individual joints. Considering the limited open motion database for gait analysis focusing on such disorders, we construct a comprehensive, openly accessible 3D full-body motion database from 45 subjects.

[The differential diagnosis of asymmetry in infants]

Asymmetry in infants is a clinical condition in which abnormal body shape, posture or mobility is observed. It is characterized by diverse etiology, localization and severity. The most frequently noted kind is idiopathic asymmetry. Symptomatic asymmetry is less frequent and a variety of structural or systemic disorders underlie this disease. The dynamics of child development in the first year of life makes it necessary for clinicians to give an early diagnosis of asymmetry, which has a significant impact on the expected course of its development and intervention strategies. The aim of the study is to present the definitions, classification and differential diagnosis of asymmetry in infants.

Social differentials in non-employment following hospital admission for musculoskeletal disorders in Sweden, 2001-2006

The article studies social differentials in non-employment among individuals who had been employed in 2001 following hospital admission for musculoskeletal disorders, by gender, educational level, and country of birth, in Stockholm County during 2001-2006. Individually linked population registers on health service use and sociodemographic characteristics were used. Individuals ages 25 to 59, living in Stockholm County and having employment in 2001, were followed until 2006. Annual age-standardized employment rates were calculated for people admitted to the hospital and diagnosed with a musculoskeletal disorder (n = 1,888) and compared to a reference group of others in employment. Multivariate Cox regression analysis was used to calculate the hazard risks of non-employment in 2006. Both women and men admitted to the hospital had lower age-standardized employment rates compared to the reference group and were at higher risk of non-employment. The hazard risk of non-employment was significantly higher among women and men with short education and among foreign-born individuals. Employment consequences of musculoskeletal disorders seem to be unequally distributed between different social groups, with women, people with short education, and people born outside Sweden more likely to be non-employed.

Impacts of differences in epidemiological case definitions on prevalence for upper-extremity musculoskeletal disorders

OBJECTIVE

The aim of this study was to systematically evaluate prevalence based on variations in case definitions used for epidemiological studies of musculoskeletal disorders (MSDs).

BACKGROUND

Prior studies of MSDs have mostly relied on a single case definition based on questionnaires.

METHOD

In a multicenter prospective cohort study, we systematically collected data to evaluate impacts of differences in case definitions of MSDs on prevalence of three common musculoskeletal disorders: (a) shoulder tendinosis, (b) lateral epicondylalgia, and (c) carpal tunnel syndrome. Production workers were from 21 employment settings in three diverse U.S. states and performed widely varying work. All workers completed laptop-administered structured interviews, two standardized physical examinations, and nerve conduction studies (NCS). Case definitions included symptoms only, and symptoms plus physical examinations and/or NCS.

RESULTS

A total of 1,227 subjects had complete health data at baseline. The prevalence for shoulder tendinosis is 23.0% if only glenohumeral pain is used for a case definition, compared with 8.0% if a combination of pain plus a positive supraspinatus test is used. The prevalence for lateral epicondylalgia varied on the basis of lateral elbow pain (12.0%), pain plus tenderness on palpation (9.9%), or pain plus tenderness on palpation plus resisted wrist or middle finger extension (3.5%). Carpal tunnel syndrome prevalence varied on the basis of tingling or numbness in a median nerve-served digit (29.9%) or tingling or numbness plus NCS abnormalities consistent with carpal tunnel syndrome (9.0%).

CONCLUSION

Variations in epidemiological case definitions have major impacts on prevalence of common MSDs. Wide-ranging differences in prevalence may have impacts on purported risk factors that need to be determined.

[Meloxicam: the golden mean of nonsteroidal anti-inflammatory drugs]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are most commonly used to treat acute and chronic pain in locomotor system (LMS) diseases. However, their administration may be accompanied by the development of dangerous complications as organic and functional disorders of the cardiovascular system (CVS) and gastrointestinal tract (GIT). Physicians have currently a wide range of NSAIDs at their disposal; but none of the representatives of this group can be considered the best. Thus, highly selective cyclooxygenase-2 inhibitors (Coxibs) are substantially safer for GIT; however, their use is clearly associated with the increased risk of severe cardiovascular events. Nonselective NSAIDs, such as naproxen or ketoprofen, are safer for CVS, but more frequently cause significant GIT organic and functional disorders. Moderately selective NSAIDs, such as meloxicam (movalis), conceivably could be the most acceptable choice for treating the majority of patients in this situation. This drug has been long and extensively used in global clinical practice and has gained the confidence of physicians and patients. The major benefits of meloxicam are its proven efficacy, convenient treatment regimen, relatively low risk of complications as organic and functional disorders of the GIT and CVD and good compatibility with low-dose aspirin.

Development of a computer-based clinical decision support tool for selecting appropriate rehabilitation interventions for injured workers

PURPOSE

To develop a classification algorithm and accompanying computer-based clinical decision support tool to help categorize injured workers toward optimal rehabilitation interventions based on unique worker characteristics.

METHODS

Population-based historical cohort design. Data were extracted from a Canadian provincial workers' compensation database on all claimants undergoing work assessment between December 2009 and January 2011. Data were available on: (1) numerous personal, clinical, occupational, and social variables; (2) type of rehabilitation undertaken; and (3) outcomes following rehabilitation (receiving time loss benefits or undergoing repeat programs). Machine learning, concerned with the design of algorithms to discriminate between classes based on empirical data, was the foundation of our approach to build a classification system with multiple independent and dependent variables.

RESULTS

The population included 8,611 unique claimants. Subjects were predominantly employed (85 %) males (64 %) with diagnoses of sprain/strain (44 %). Baseline clinician classification accuracy was high (ROC = 0.86) for selecting programs that lead to successful return-to-work. Classification performance for machine learning techniques outperformed the clinician baseline classification (ROC = 0.94). The final classifiers were multifactorial and included the variables: injury duration, occupation, job attachment status, work status, modified work availability, pain intensity rating, self-rated occupational disability, and 9 items from the SF-36 Health Survey.

CONCLUSIONS

The use of machine learning classification techniques appears to have resulted in classification performance better than clinician decision-making. The final algorithm has been integrated into a computer-based clinical decision support tool that requires additional validation in a clinical sample.

Development and evaluation of a Naïve Bayesian model for coding causation of workers' compensation claims

INTRODUCTION

Tracking and trending rates of injuries and illnesses classified as musculoskeletal disorders caused by ergonomic risk factors such as overexertion and repetitive motion (MSDs) and slips, trips, or falls (STFs) in different industry sectors is of high interest to many researchers. Unfortunately, identifying the cause of injuries and illnesses in large datasets such as workers' compensation systems often requires reading and coding the free form accident text narrative for potentially millions of records.

METHOD

To alleviate the need for manual coding, this paper describes and evaluates a computer auto-coding algorithm that demonstrated the ability to code millions of claims quickly and accurately by learning from a set of previously manually coded claims.

CONCLUSIONS

The auto-coding program was able to code claims as a musculoskeletal disorders, STF or other with approximately 90% accuracy.

IMPACT ON INDUSTRY

The program developed and discussed in this paper provides an accurate and efficient method for identifying the causation of workers' compensation claims as a STF or MSD in a large database based on the unstructured text narrative and resulting injury diagnoses. The program coded thousands of claims in minutes. The method described in this paper can be used by researchers and practitioners to relieve the manual burden of reading and identifying the causation of claims as a STF or MSD. Furthermore, the method can be easily generalized to code/classify other unstructured text narratives.

Cluster analysis of symptoms among patients with upper extremity musculoskeletal disorders

INTRODUCTION

Some musculoskeletal disorders of the upper extremity are not readily classified. The study objective was to determine if there were symptom patterns in self-identified repetitive strain injury (RSI) patients.

METHODS

Members (n = 700) of the Dutch RSI Patients Association filled out a detailed symptom questionnaire. Factor analysis followed by cluster analysis grouped correlated symptoms.

RESULTS

Eight clusters, based largely on symptom severity and quality were formulated. All but one cluster showed diffuse symptoms; the exception was characterized by bilateral symptoms of stiffness and aching pain in the shoulder/neck.

CONCLUSIONS

Case definitions which localize upper extremity musculoskeletal disorders to a specific anatomical area may be incomplete. Future clustering studies should rely on both signs and symptoms. Data could be collected from health care providers prospectively to determine the possible prognostic value of the identified clusters with respect to natural history, chronicity, and return to work.

Costs by industry and diagnosis among musculoskeletal claims in a state workers compensation system: 1999-2004

BACKGROUND

Musculoskeletal disorders (MSDs) are a tremendous burden on industry in the United States. However, there is limited understanding of the unique issues relating to specific industry sectors, specifically the frequency and costs of different MSDs.

METHODS

Claim data from 1999 to 2004 from the Ohio Bureau of Workers' Compensation were analyzed as a function of industry sector (NAICS industry-sector categories) and anatomical region (ICD-9 codes).

RESULTS

Almost 50% of the claims were lumbar spine (26.9%) or hand/wrist (21.7%). The majority of claims were from manufacturing (25.1%) and service (32.8%) industries. The industries with the highest average costs per claim were transportation, warehouse, and utilities and construction. Across industries, the highest costs per claim were consistently for the lumbar spine, shoulder, and cervical spine body regions.

CONCLUSION

This study provides insight into the severity (i.e., medical and indemnity costs) of MSDs across multiple industries, providing data for prioritizing of resources for research and interventions.

Musculoskeletal injuries

In 2007-2009, BEACH (Bettering the Evaluation and Care of Health) recorded 979 encounters at which a possible sports related injury was managed in a patient aged 5-24 years. Although there is no way of determining the cause of an injury through BEACH data, we selected musculoskeletal injuries which could be caused by a sporting activity, excluding problems that were said to be work related, and limited the sample by the age of patient.

Towards an outcome documentation in manual medicine: a first proposal of the International Classification of Functioning, Disability and Health (ICF) intervention categories for manual medicine based on a Delphi survey

AIM

The International Classification of Functioning, Disability and Health (ICF) provides a useful framework for the comprehensive description of the patients' functional health. The aim of this study was to identify the ICF categories that represent the patients' problems treated by manual medicine practitioners in order to facilitate its application in manual medicine. This selection of ICF categories could be used for assessment, treatment documentation and quality management in manual medicine practice.

METHODS

Swiss manual medicine experts were asked about the patients' problems commonly treated by manual medicine practitioners in a three-round survey using the Delphi technique. Responses were linked to the ICF.

RESULTS

Forty-eight manual medicine experts gave a total of 808 responses that were linked to 225 different ICF categories; 106 ICF categories which reached an agreement of at least 50% among the participants in the final Delphi-round were included in the set of ICF Intervention Categories for Manual Medicine; 42 (40%) of the categories are assigned to the ICF component body functions, 36 (34%) represent the ICF component body structures and 28 (26%) the ICF component activities and participation.

CONCLUSION

A first proposal of ICF Intervention Categories for Manual Medicine was defined and needs to be validated in further studies.

[Indication of chemotherapy according to histological type of musculoskeletal sarcomas]

In high-grade musculoskeletal sarcomas, adjuvant chemotherapy is often performed to prevent distant metastases. As the efficacy of chemotherapy varies according to the histological type of sarcoma, its indication is determined according to the histological type and the stage. Prognoses are poor in patients with osteosarcoma, Ewing's sarcoma, or rhabdomyosarcoma, when surgery alone is performed. However, because these sarcomas are chemosensitive, their prognoses are improved with adjuvant chemotherapy, so it is absolutely necessary. Drugs commonly used for osteosarcoma include adriamycin, cisplatin, methotrexate, vincristine, and ifosfamide. For Ewing's sarcoma and rhabdomyosarcoma, vincristine, actinomycin-D, cyclophosphamide, etoposide, and ifosfamide are commonly used. On the other hand, the efficacy of chemotherapy is unclear in most of the non-round cell sarcomas, e. g., malignant fibrous histiocytoma, pleomorphic liposarcoma, and leiomyosarcoma, so adjuvant chemotherapy is relatively indicated and often performed preoperatively. The efficacy is evaluated by reduction of the tumor volume as a surrogate marker. Postoperative chemotherapy is performed when the preoperative chemotherapy is effective. Nowadays, several kinds of antitumor agents are usually used for non-round cell sarcomas, and many authors have reported various kinds of regimens and their clinical results. Among them, the key drugs are adriamycin and ifosfamide. Recently, taxanes and gemcitabine are sometimes used. For chemoresistant sarcomas, e. g., chondrosarcoma, chordoma, alveolar soft part sarcoma, chemotherapy is rarely indicated, even if the tumor is histologically high grade and large. Low-grade musculoskeletal sarcomas, e. g., low-grade chondrosarcoma, central low-grade osteosarcoma, parosteal osteosarcoma, well-differentiated liposarcoma, and dermatofibrosarcoma protuberans, are well cured only by surgical excision, and adjuvant chemotherapy is therefore not indicated. Superficially-located, small-size non-round cell sarcomas, even though histologically high grade, are well healed only by surgical excision, and adjuvant chemotherapy is rarely indicated.

[Diagnosis coding of the musculoskeletal system in general practice]

INTRODUCTION

Danish general practitioners are encouraged to code diagnoses according to the Danish version of ICPC. In order to evaluate feasibility, we aimed to estimate sensitivity of ICPC coding of patients with symptoms from the musculoskeletal system (ICPC L01-20 and 83-99) in general practice compared to health information from other sources.

MATERIALS AND METHODS

We identified patients connected to one general practice in July 2005. We retrieved information on referred care by specialists in neurology, rheumatology, and orthopaedic surgery as well as treatments by physiotherapists from the Danish Health Insurance. We received ICD10 codes within chapter 8 (diseases of the musculoskeletal system and connective tissue) from the Danish Hospital Register. Sensitivity was calculated according to criteria based on whether the patients had received an ICD10 code or other public health services.

RESULTS

Of 2649 patients registered in the general practice, 496 had recorded an ICPC code in chapter L (the musculoskeletal system). Sensitivity was calculated to 0.83. Of all patients with musculoskeletal diseases 82.5% were identified by ICPC codes, but only 45% by other health sources.

CONCLUSION

The coding of ICPC in a general practice had an acceptable sensitivity and constitutes a useful opportunity to identify a group of patients with musculoskeletal diseases. An optimal identification of specific patient subgroups, by using ICPC coding, requires the construction of a national registry of the ICPC coding made in all Danish general practices.

Ultrasound biomicroscopy of zonular anatomy in clinically unilateral exfoliation syndrome

PURPOSE

To evaluate the ability of ultrasound biomicroscopy (UBM) to detect abnormalities in the zonular apparatus in unaffected eyes of patients with clinically unilateral exfoliation syndrome (XFS) using a standardized grading system.

METHODS

The affected and unaffected eyes of 17 patients with clinically unilateral XFS and 17 eyes of 17 control subjects underwent UBM. Radial sections detailing the lens and zonules at 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00 and 10:30 clock hours were obtained. The images were graded by a masked, experienced UBM observer using a standardized scoring system based on the zonular appearance (0, none; 1 and 2, uneven or disrupted zonules with or without patchy deposits; 3, diffuse granulation, thick zonules or both; 4, total zonular disruption). Affected meridians were compared by the Friedman test, while distributions of unaffected and affected eyes were compared using the Student t-test.

RESULTS

In the control group, 15/17 eyes showed normal zonules; the remaining two eyes showed grade 1 changes in some meridians. The mean grade score was 0.33 [standard deviation (SD) 0.84]. Eyes with XFS had a higher score than control eyes, with a mean score of 14.35 (SD 7.14, P < 0.001, Student t-test). In clinically unaffected fellow eyes, the mean score was 10.53 (SD 7.44), and was less than that of XFS eyes (P = 0.008, Student t-test). Twelve XFS eyes (71%) and six unaffected fellow eyes (35%) had grade 3 or 4 in at least one meridian (P = 0.07, Friedman test).

CONCLUSION

Bilateral zonular involvement is present in subjects with clinically unilateral XFS. These zonular changes may be extensive in fellow eyes without clinically evident exfoliation material. UBM assessment of zonular status in fellow eyes prior to cataract extraction may aid in surgical planning.

[Musculo-skeletal disorders of the upper limb in the "new tables of professional diseases in industry and agriculture"]

The author, after an analysis of the statistical data on work-related diseases reported to the INAIL and listed on the Annual Report 2007, examines the main highlights of the "new tables of professional diseases in industry and agriculture" published in the Ministerial Decree of July 21st, 2008 (GU n.169, 21-7-2008), also relating to the introduction of musculo-skeletal disorders of the upper limb due to bio-mechanical strain into the list of professional diseases to which the legal presumption of origin is applicable.

Age, work limitations and physical functioning among construction roofers

BACKGROUND

To investigate the intersection of aging with work limitations, chronic medical and musculoskeletal conditions, and physical functioning we undertook a cross-sectional study of U.S. construction roofers who were current union members between the ages of 40 and 59.

METHODS

Participants were asked about the presence of medical conditions and musculoskeletal disorders (MSDs); the Work Limitations Questionnaire, the SF-12, and other validated assessments of social and economic impact of injury were included.

RESULTS

Sixty-nine percent had at least one of these conditions in the previous two years; 31% missed work. Workers with medical and musculoskeletal conditions were older, had the highest prevalence of work activity limitations, and had the lowest SF-12 scores.

CONCLUSIONS

Older age was associated with the presence of a medical condition, and with reduced physical functioning. Medical and musculoskeletal conditions were strongly associated with work limitation, missed work, and reduced physical functioning. Older workers may be at higher risk of disability retirement compared to younger workers with similar medical conditions and work limitations.

Assessing and managing patients with musculoskeletal conditions

This article discusses the anatomy and physiology of the musculoskeletal system and some common presenting complaints. Examination techniques and principles of nursing care are considered.

Disabling our diagnostic dilemmas

The physical therapy profession's diagnostic dilemma results from its confused response to competing issues that affect the physical therapist's role as a diagnostician. The major components of the diagnostic dilemma are: (1) the competition among new ideas, (2) the complexity of the diagnostic process and language used to describe the outcome, (3) the profession's lack of consensus regarding the diagnostic classification construct to be embraced, and (4) the rapid evolution and impact of new knowledge. The interaction of these 4 components results in "diagnostic disablement." Whether managing a patient, creating a curriculum to educate new physical therapy practitioners, or applying for research funding to study the science or practice of diagnostic classification, physical therapists face a real challenge in understanding and complying with all the current diagnostic requirements of the US health care system and the physical therapy profession. This article traces the 4 components and considers the strategies the profession can use to resolve its diagnostic dilemma. The first step would be to standardize the language that physical therapists use to describe or diagnose phenomena within their scope of practice.

Chronic musculoskeletal problems managed in general practice

The BEACH program, a continuous national study of general practice activity in Australia, gives us an overview of encounters at which chronic musculoskeletal problems were managed. This synopsis provides a backdrop against which articles in this issue of the Australian Family Physician can be further considered.

Development of the effective musculoskeletal consumer scale

Programs and initiatives have been created to empower, educate, and provide information to consumers; these are sometimes generically known as self-management interventions. Evaluating and comparing such programs has been a challenge, as many skills that consumers believe are important to manage and participate in their individual healthcare are not currently captured by existing tools. The objective of the Effective Musculoskeletal Consumer Project is to develop a scale to measure an effective consumer. A review of the literature, interviews, workshops, and preliminary surveys at OMERACT 7 (May 2005) were conducted in the first phases of the Project. A questionnaire consisting of 64 items was developed to measure the skills and attributes of an effective musculoskeletal (MSK) consumer. Content experts on our team reduced this scale to 48 items, which was pilot-tested with consumers from Canada and Australia. Dimensionality assessment showed that the scale was unidimensional. Classical and item response theory analyses showed that the 48-item scale had quite high reliability, but that 2 items were very poor. Based on the item analysis, 35 items were retained. The revised scale was presented at OMERACT 8, where a panel reviewed the scale and provided input. This input and another expert review by our team was used to further refine the Effective Consumer Scale to 17 items. Plans are now under way to validate this 17-item scale in self-management interventions.

The relationship between working conditions and sick leave in Swedish dental hygienists

The purpose of this study was to examine the relationship between working conditions and sick leave in Swedish dental hygienists. Seventy-one percent of 577 randomly selected dental hygienists responded to a questionnaire. From those who responded (n=411) a homogenous group of 252 was selected. They were assigned to four groups that exhibited either musculoskeletal disorders (MSD), low well-being (LWB), both low well-being and musculoskeletal disorders (BLM), or relative health (main group or M group). These groups were further divided according to number of sick days taken per year. Non-parametric statistics and logistic regressions were used for analyses. Those with MSD worked more clinical hours and treated more patients per day than the other groups. While the M group had fewer sick days, better work climates and decreased demands on work efficiency, increased sick leave within this group was related to greater staff numbers and less commitment to improving work processes. In the M group, role ambiguity and LWB were associated with absence of 1-3 days, compared with those who took no sick leave. Respondents in the LWB group, who perceived role ambiguity, were absent more than 7 days/year, compared with those who perceived role clarity. Management issues were the distinguishing factor for those who had severe health problems.

IN CONCLUSION

role ambiguity is the predominant psychosocial factor associated with sick leave. Psychosocial management factors rather than physical work factors seem important for work and sick leave rates among dental hygienists.

A pattern recognition approach to the development of a classification system for upper-limb musculoskeletal disorders of workers

OBJECTIVES

Workers' musculoskeletal disorders are often pain-based and elude specific diagnoses; yet diagnosis or classification is the cornerstone to researching and managing these disorders. Clinicians are skilled in pattern recognition and use it in their daily practice. The purpose of this study was to use the clinical reasoning of experienced clinicians to recognize patterns of signs and symptoms and thus create a classification system.

METHODS

Two hundred and forty-two workers consented to a standardized physical assessment and to completing a questionnaire. Each physical assessment finding was dichotomized (normal versus abnormal), and the results were graphically displayed on body diagrams. At two different workshops, groups of experienced researchers or clinicians were led through an exercise of pattern recognition (clustering and naming of clusters) to arrive at a classification system. Interobserver reliability was assessed (8 observers, 40 workers), and the classification system was revised to improve reliability.

RESULTS

The initial classification system had good face validity but low interobserver reliability (kappa <0.3). Revisions were made that resulted in a proposed triaxial classification system. The signs and symptoms axes quantified the areas in the involved upper limbs. The proposed third axis described the likelihood of a specific clinical diagnosis being made and the degree of certainty. The interobserver reliability improved to approximately 0.70.

CONCLUSIONS

This triaxial classification system for musculoskeletal disorders is based on clinically observable findings. Further testing and application in other populations is required. This classification system could be useful for both clinicians and epidemiologists.

Musculoskeletal disorders (Msds) and dental practice. part 1. General information-terminology, aetiology, work-relatedness, magnitude of the problem, and prevention

Occupational health hazards are common in many sectors and are on the increase. Musculoskeletal disorders (MSDs), which are problems of musculoskeletal system, are significant and costly workplace problems affecting occupational health, productivity and the careers of the working population. Although there is a lack of uniform medical information and a clear understanding of the nature of MSDs, and significant difficulties in diagnosis which generate an ongoing debate regarding many aspects of these conditions, various risk factors are identified and preventive measures are available. As safety and health at work is a realistic target and prevention is clearly the best approach, the preventive philosophy deserves particular attention. This review aims to provide background information on general features of MSDs, identified risk factors and the basic philosophy of prevention.

Current issues in case definitions for common musculoskeletal disorders in workers for clinical practice and research

BACKGROUND

Several reviews and attempts at meta-analysis have pointed out that comparisons between studies on work-related musculoskeletal disorders are problematic, since different studies use different case definitions. In a clinical setting, the case definition involves a detailed history, a physical examination, and laboratory testing.

DISCUSSION AND CONCLUSIONS

When determining which tests should be included in a clinical examination, it is necessary to take into consideration the characteristics of clinical tests in terms of likelihood ratio for confirming and ruling out disease in addition to the pre-test probability of disease. If the different musculoskeletal symptoms and signs do not completely comply with the criteria for a disease, we recommend the choice of an ICD label (International Classification of Diseases - WHO) that focuses on the symptoms rather than the pathology. We suggest that the process for a new feasible case definition system for the neck and upper extremities should start with the creation of a consensus of criteria for diagnosis of common musculoskeletal disorders in primary care, developed by a panel consisting of researchers in the key disciplines. Furthermore, we suggest that in workers whose musculoskeletal function is crucial for employment, use of the International Classification of Function (ICF) may be one way to improve classification of health problems.

A review of initial entry training discharges at Fort Leonard Wood, MO, for accuracy of discharge classification type: fiscal year 2003

OBJECTIVE

This study examines the extent to which discharges from Initial Entry Training can be adequately characterized by the current policy of a single descriptive category.

METHODS

Service records of each trainee discharged from Fort Leonard Wood in 2003 were examined. Discharged trainee's counseling and outpatient clinic visit records were reviewed for evidence of multiple reasons for discharge.

RESULTS

Evidence of medical involvement was found by record review in 13% of administrative discharges. Among discharges classified as being for medical or physical conditions that did not exist before service, 17% had clear evidence of preexisting chronic conditions.

CONCLUSION

The policy of allowing only one categorization code to describe reasons for an Initial Entry Training discharge frequently resulted in incomplete characterization of factors leading to discharge. Pre-existing medical and mental health conditions were found in a much greater percentage of discharges than indicated by a simple review of discharge codes.

Profiling schoolchildren in pain and associated demographic and behavioural factors: a latent class approach

Musculoskeletal pain in adolescence is common and individuals frequently report pain in different sites. However, statistical analysis is often limited to considering one or a few pain sites. In this study latent class analysis was used to classify individuals into latent classes in terms of their patterns of endorsing ten musculoskeletal sites. Previously established covariates of musculoskeletal pain in adolescents were then assessed across emergent latent classes. The study was a cross sectional survey of adolescents attending post-primary schools in England. A total of 679 took part in the study with an age range from 11 to 14 years. Pain was operationalised as the occurrence of pain for one day or more in the past month. Schoolchildren self-reported on the incidence of pain aided by a nordic manikin. A three-class model emerged as the best fit. Classes were labelled 'Pain free' (63.4%), 'Neck and back' pain (28.2%) and 'Widespread' pain (8.4%). The 'Widespread' pain class was significantly related with Age (OR=1.79; 95%CI 1.24-2.57), Sex (OR=0.35, 95%CI 0.16-0.79), bag weight to body weight (OR=1.12, 95%CI 1.03-1.22), bag carrying method (OR=2.08, 95%CI 1.08-3.97), Schoolwork difficult (OR=2.78, 95%CI 1.27-6.07), and headaches (OR=2.13, 95%CI 1.65-2.76). While Strengths and Difficulties Questionnaire scores (OR=1.05, 95%CI 1.01-1.11), and Headaches (OR=1.78, 95%CI 1.39-2.26) were significant for the 'Back and neck' class. It is suggested that research should seek to identify typical pain profiles for adolescents, rather than concentrating on specific pain sites since some risk factors may be obscured or inflated by inappropriately amalgamating or segregating pain sites.

Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder

BACKGROUND

There is no universally accepted way of labelling or defining upper-extremity musculoskeletal disorders. A variety of names are used and many different classification systems have been introduced.

OBJECTIVE

To agree on an "unambiguous language" concerning the terminology and classification that can be used by all relevant medical and paramedical disciplines in the Netherlands.

METHODS

A Delphi consensus strategy was initiated. The outcomes of a multidisciplinary conference were used as a starting point. In total, 47 experts in the field of upper-extremity musculoskeletal disorders were delegated by 11 medical and paramedical professional associations to form the expert panel for the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis and a feedback report.

RESULTS

After three Delphi rounds, consensus was achieved. The experts reported the consensus in a model. This so-called CANS model describes the term, definition and classification of complaints of arm, neck and/or shoulder (CANS) and helps professionals to classify patients unambiguously. CANS is defined as "musculoskeletal complaints of arm, neck and/or shoulder not caused by acute trauma or by any systemic disease". The experts classified 23 disorders as specific CANS, because they were judged as diagnosable disorders. All other complaints were called non-specific CANS. In addition, the experts defined "alert symptoms" on the top of the model.

CONCLUSIONS

The use of the CANS model can increase accurate and meaningful communication among healthcare workers, and may also have a positive influence on the quality of scientific research, by enabling comparison of data of different studies.

Prognosis in soft tissue disorders of the shoulder: predicting both change in disability and level of disability after treatment

BACKGROUND AND PURPOSE

Clinicians often are faced with questions about prognosis and outcome of shoulder disorders. The purpose of this study was to identify predictors of both change in disability and level of disability following physical therapy treatment.

SUBJECTS

The subjects were consecutive patients (n=361) who were receiving physical therapy for soft tissue shoulder disorders.

METHODS

Clinical response to physical therapy, which was measured using the Disabilities of the Arm, Shoulder, and Hand (DASH) measure, was assessed over 12 weeks. The 28 independent baseline predictors included demographics, disorder-related and disability measures, medication use, clinical findings, and expectations for recovery. Multiple linear regression techniques were used.

RESULTS

Predictors of greater disability at discharge were: higher initial disability, therapist prediction of restricted activities at discharge, workers' compensation claim, older age, and being female. Predictors of greater improvement in disability were: shoulder surgery, higher pain intensity, shorter duration of symptoms, younger age, and poorer general physical health (measured using the 36-Item Short-Form Health Survey [SF-36]).

DISCUSSION AND CONCLUSIONS

Prognostic factors differ depending on the format of the outcome. Only age was significant in both models.

Work-related musculoskeletal disorders with reference to the revised occupational diseases list

Due to the different compensation schemes, compensated musculoskeletal disorders vary widely between countries. In Italy, following the Constitutional Court Decision no.179/1988, these disorders were treated as "non-listed" diseases and workers must prove their occupational origin by submitting a compensation claim for musculoskeletal disorders to INAIL. The Italian Workers Compensation Agency (INAIL) supplied guidelines for the management of these claims. Recently, a new occupational diseases list has been submitted to the Labour Ministry for approval. This list includes musculoskeletal disorders of the upper limb, back and knee.

Attributed disability: a spot of local difficulty

There has been an exponential growth of publications relating to the development and application of health measurement instruments. Condition-specific measures have formed a large part of this trend. This article questions the rationale behind the concept of condition-specific disability, a common domain in such measures, taking musculoskeletal medicine as an example. It argues that physical functions are seldom unique to a specific condition and that measurement specificity therefore relies on attributing functional consequences to the health condition of interest. The presence of multi-morbidity (musculoskeletal and non-musculoskeletal), and the influence of personal and environmental factors, pose problems for attribution that have seldom been empirically investigated. Furthermore, attributing disability to a specific health condition of interest potentially limits insights into important interventions such as managing co-morbid interactions and targeting barriers in the physical, social, and attitudinal environment. Efforts to identify regionally relevant item content and to measure participation in daily life are a step in the right direction. Attribution is not needed for either.

The new injury severity score: better prediction of functional recovery after musculoskeletal injury

OBJECTIVES

Injury Severity Score (ISS) is the most widely used method of assessing severity of injury in blunt trauma. It has been recognized that, by only allowing the score to consider the worst injury for each body system, ISS underestimates the problems of multiple musculoskeletal injuries. The New ISS (NISS) allows the three most severe injuries to be scored, irrespective of region affected, and may give better prediction of functional recovery in these patients.

METHODS

A prospective cohort study of 200 patients with musculoskeletal injuries, examining the predictive value of ISS and NISS on functional recovery as measured by patient-derived outcome measures (Short Form-36, Sickness Impact Profile, and Musculoskeletal Function Assessment).

RESULTS

NISS was greater than ISS in 34 patients (17%). NISS showed closer correlation with total scores and subscores of the outcomes measures than did ISS (Spearman's rho ranked test, P < 0.05).

CONCLUSIONS

NISS, a simple modification from ISS, better predicts functional outcomes in survivors of musculoskeletal trauma, and offers an improvement in the assessment of effectiveness of trauma care delivery.

Channeling and prevalence of cardiovascular contraindications in users of cyclooxygenase 2 selective nonsteroidal antiinflammatory drugs

OBJECTIVE

To assess use and channeling of cyclooxygenase 2 selective inhibitors (coxibs) over time and to estimate the percentage of coxib users with cardiovascular contraindications.

METHODS

The study population comprised all coxib and nonselective nonsteroidal antiinflammatory drug (NSAID) users in the Integrated Primary Care Information project between January 2000 and December 2004. The prevalence of risk factors for NSAID-related upper gastrointestinal ulcer complications, cardiovascular disease, and cerebrovascular disease at the start of treatment was compared between users of coxibs and users of nonselective NSAIDs.

RESULTS

The study population included 72,841 nonselective NSAID users and 10,739 coxib users. The prevalence of risk factors for NSAID-related gastrointestinal complications was higher in coxib users than nonselective NSAID users (odds ratio [OR] 1.18, 95% confidence interval [95% CI] 1.10-1.26). Similarly, the prevalence of prior cardiovascular disease was higher in coxib users than in nonselective NSAID users (OR 1.35, 95% CI 1.28-1.43). Channeling of coxibs to patients with NSAID-related gastrointestinal risk factors declined after 2001 but increased again in 2004, whereas the channeling of coxibs to patients with cardiovascular disease remained constant. Less than 15% of all coxib users had history of ischemic coronary or cerebrovascular disease. Among coxib users with increased risk for NSAID-related gastrointestinal disorders, 27% had history of ischemic coronary or cerebrovascular disease.

CONCLUSION

This study demonstrates that coxibs were preferentially prescribed to patients with risk factors for NSAID-related gastrointestinal disorders and/or cardiovascular diseases. Only one-quarter of coxib users with increased risk for NSAID-related gastrointestinal complications had cardiovascular conditions compatible with recent European safety contraindications for coxibs.

Doenças do sistema osteomuscular em trabalhadores de enfermagem

Esta pesquisa, de caráter descritivo e retrospectivo, realizada na Fundação Hospitalar do Estado de Minas Gerais-Brasil, teve por objetivo analisar os problemas de saúde relacionados ao sistema osteomuscular encontrados nos trabalhadores de enfermagem de 23 instituições de saúde, atendidos pela Divisão de Assistência à Saúde do Trabalhador, em 2002. Os dados foram coletados nos mapas de atendimentos e nos prontuários médicos norteados por um roteiro elaborado pelos autores. Os diagnósticos foram agrupados segundo o Código Internacional de Doenças CID-10 e comparados à Lista de doenças relacionadas ao trabalho do Ministério da Saúde. Na análise dos dados, utilizou-se o programa estatístico SPSS. Entre os 6070 atendimentos realizados, 11,83% deles (718) apresentaram diagnósticos de problemas relacionados ao sistema osteomuscular, envolvendo diversas estruturas corporais como a coluna vertebral, membros superiores e inferiores. As doenças legalmente consideradas como doenças do trabalho relacionadas ao sistema músculo-esquelético foram identificadas em 255 (35%) atendimentos, destacando-se as dorsalgias (20%) e as sinovites e tenossinovites (13,7%), agrupadas como LER-DORT. Conclui-se que maior atenção deva ser direcionada às posturas adotadas pelos trabalhadores na execução das atividades laborais e às condições dos mobiliários, bem como se faz necessário disponibilizar instrumentos e equipamentos ergonomicamente planejados, visando à redução da incidência dos problemas osteomusculares.

Musculoskeletal colloquialisms: how did we come up with these names?

Eponyms and colloquial terms are labels that provide two kinds of information: the pattern of a complex injury or pathologic problem and, in the case of an eponym, the name of an individual who has been closely identified with the pathologic problem. Such terms remind us that the medicine of today is not entirely the work of our contemporaries. The article illustrates many of the common colloquial terms applied to fractures and musculoskeletal injuries seen in everyday practice. Wherever possible, the illustrations and definitions are based on the original descriptions of the injuries.

[Developing rehabilitation treatment groups for cardiology and orthopaedics -- findings of a research project]

The call for a more specific and transparent service and reimbursement system for medical rehabilitation is not new. However, in practice, the idea was not followed up for a long time. This situation changed with the introduction of German Diagnosis Related Groups (DRGs) for acute care settings. It is now strongly being discussed whether such a sophisticated lump sum reimbursement system might also be a viable alternative in the field of rehabilitation. There still exist different opinions over the suitability of a lump sum-system for medical rehabilitation, but the main direction seems to be clear. There is no doubt that medical rehabilitation requires a needs-adapted, differentiated patient classification system. The benefits of such cost-homogeneous groups are evident. They support medical and management services and are suitable for both internal and external use. The main intent of the project presented was to develop such a patient classification system, adapted to the requirements of medical rehabilitation. The project concentrated on orthopaedic and cardiac rehabilitaton. For these two areas, needs-adapted and cost-homogeneous groups (RBG, Rehabilitationsbehandlungsgruppen - Rehabilitation Treatment Groups) were developed in order to adequately represent the underlying service portfolio and to act as a link between acute and post-acute care. In addition, severity level indicators were identified, in order to explain for different needs and resource volumes and in order to create severity-RBGs representing patients with the same severity level. Based on these groups, a needs-adapted lump sum reimbursement system can be developed, allowing for a differentiated service and cost controlling. The project described formed part of the Research Funding Programme Rehabilitation Sciences defrayed by the German Pension Insurance and the Federal Ministry for Education and Research. As part of the Freiburg/Bad Sackingen research network, it was realised at the University BW, Munich.

[Criteria for classification of upper limb work-related musculo-skeletal disorders due to biomechanical overload in occupational health. Consensus document by an Italian Working Group]

BACKGROUND AND OBJECTIVE

In a preliminary consensus document the authors proposed criteria and methods to identify upper limb work-related MSDs due to biomechanical overload. With this document they intend to define severity according to shared models and procedures so as to fit behaviours to diagnostic procedures and their medical-legal assessment. This becomes especially important in view of Ministerial Decree of April 27 2004 fixing the new lists of diseases having a possible work-related origin that must be reported by law in accordance with art. 139 of law n. 1124, and also on account of the impact of such diseases which, for the first time in Italy, are regulated by law.

CONTENTS

The working group, which included INAIL and ISPESL experts and was fully supported by SIMFER (Italian Society of Physical Medicine and Rehabilitation) and SINC (Italian Society of Clinical Neurophysiology), defined a general clinical procedure (anamnesis, objective examination and instrumental assessment) regarding each portion of the concerned upper limb (shoulder, elbow and wrist/hand). Once the presence and characteristics of anatomic and functional damages are established, the results allow a classification scheme to be proposed of upper limb diseases (tendon disorders and entrapment neuropathy) divided into 6 increasing severity stages: initial, medium, medium-severe, severe and extremely severe. Special attention was paid to two instrumental examinations that proved to be of great clinical interest, at least in occupational health: echography of soft tissues (in appendix) and electroneurography for entrapment neuropathy. The limitations of this proposal are discussed but the main goal was achieved: to standardize terms and provide homogeneous criteria to achieve classification of upper limb damage due to biomechanical overload for increasing severity levels. The working group research activity is part of a research project funded by ISPESL.

Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy)

The majority of patients with Achilles tendinopathy respond to nonoperative treatment. In patients with refractory symptoms, surgery can be considered. If paratenonitis is present, the paratenon is partially excised, and adhesions are released. Areas of symptomatic tendinosis are excised with repair of the residual defect in the Achilles tendon. An alternative for patients with tendinosis who are at increased risk for wound problems or who do not want a large open incision is percutaneous or endoscopic tenotomy. A symptomatic Haglund's deformity or inflamed retrocalcaneal bursa is excised. Augmentation of the Achilles tendon may be considered if debridement threatens the structural integrity of the tendon, in older patients, and in revision surgery.