April 2017

The Window of Opportunity in Arthritis Treatment:  How USBJI Can Keep it Open

As a field, rheumatology is undergoing a revolution in thinking made possible by advances in the scientific understanding of disease as well as the availability of new therapies.  At a recent meeting, I attended a lecture on an emerging concept in the treatment of rheumatoid arthritis (RA) called the window of opportunity.  The window of opportunity represents a period of time during the course of RA in which treatment may be uniquely effective in influencing the long-term course of disease.  This effect may be to reduce the total time and intensity of treatment to keep disease under control or even to induce a state of remission or low disease activity.  If substantiated further by rigorous clinical trials, the concept of window of opportunity would represent a “game changer” in the field of rheumatology.

The change in the treatment landscape of RA has been remarkable.  RA is the most common form of inflammatory arthritis that, if not treated adequately, can lead to severe pain, deformity and disability.  In the past, this condition limited both quality of life and longevity, with the diagnosis of RA often carrying a grim prognosis.  The prospects for patients are now dramatically better.  Current treatment involves the initiation of therapy early in the course of disease (“early aggressive therapy”) prescribed to “treat to target” or “T2T.”  The target is remission or low disease activity which can be assessed by a joint count (number of tender and swollen joints), an objective measure of inflammation (C-reactive protein or sedimentation rate), and a patient global assessment (“on a scale of 0 to 10, how is your arthritis?”).

While T2T therapy can produce remissions in an increasing number of patients, many patients do not respond adequately to current treatment and, when evaluated initially, already show evidence of joint damage as seen by X-ray examination of joints.  Furthermore, many patients may not get rheumatologic care until months or years following the onset of symptoms.  This delay occurs because patients are not aware that their joint pain and other symptoms such as fever or fatigue result from an inflammatory arthritis.  Unfortunately, providers may also not recognize the signs and symptoms of RA, especially early in disease course where findings of joint tenderness and swelling may be subtle.  As a result, time passes, arthralgia turns into arthritis, and a window of opportunity may close.

The existence of the window of opportunity has not yet been fully verified but the concept makes sense and data do suggest that the earlier the treatment is begun, the better the long-term outcome.  It is therefore important to initiate therapy as soon as possible since it may be able to hit the target more accurately and more frequently.  Using another metaphor, as rheumatologists, we like to put out the fire when it is just smoking and not yet blazing.  As this point, the issue becomes one of public health and improving the conditions in the health care system for patients and providers to implement best practices in a patient centric way.

When a health care issue moves into the arena of public health, organizations like the United States Bone and Joint Initiative (USBJI) have a critical role especially when partnering with constituent organizations like the American College of Rheumatology and the Arthritis Foundation.  Improvements in public health require awareness, advocacy and education.  The USBJI, through BMUS, has provided critical information on the frequency and impact-both personal and societal-of conditions like RA to raise awareness of the problem and underpin advocacy for resources to assure that all patients with an inflammatory arthritis can receive appropriate care.  Furthermore, USBJI advances research and training, with the Young Investigator Initiative (YII) boosting the academic careers of those who, for example, would like to develop tools to detect RA earlier or design treatment strategies that can be applied during any window of opportunity to slow if not halt disease progression.

Through its Experts in Arthritis program (EIA), the USBJI can educate the public about the nature of arthritis and steps that patients can personally take to achieve better outcomes.  I am very pleased that the American College of Rheumatology has recently agreed to cooperate with the USBJI on this valuable program, identifying EIA as an activity of micro-volunteerism for ACR members.  Having myself given public education programs, I am convinced of the value of the dialogue between an expert and patient about the nature of arthritis.  Unfortunately, the public still has many misconceptions about the nature of arthritis.  These misconceptions urgently need correction.  The major one is that arthritis is an inevitable consequence of aging.  Simply, RA is not a problem of aging and patients need to seek specialty care when they become symptomatic so that therapy can be begun promptly.

Finally, through its MS4 program, under the leadership of Dr. Bruce Browner, the USBJI is designing a curriculum that will increase knowledge of musculoskeletal disease for medical students.  Despite the frequency of musculoskeletal conditions in the population (a point BMUS clearly documents), most medical schools devote very limited time to education about their pathophysiology.  Time spent on the anatomy of muscle and bones is not the same as time spent on the etiology and pathogenesis of RA or osteoporosis and their treatment.  It is essential that medical school curricula devote adequate time for conditions like RA which affects 1% of the population and, according to BMUS, entails huge costs.  The MS4 program is an exciting initiative since it is interdisciplinary and will engage many constituent organizations of the USBJI.

The development of biological agents such as TNF blockers and the new targeted synthetic disease modifying anti-rheumatic drugs like the JAK inhibitors to treat RA has been extraordinary and provides the tools to enhance patient outcomes and quality of life even further than now possible.  I am very glad that the USBJI is taking a lead in this area and is working with its constituent organizations to make sure that everyone knows that there may be a window of opportunity and that patients have access to subspecialty care before the window closes.
 

The US Bone and Joint Initiative (USBJI) has had the consistent goal of increasing the amount of time and effort in medical schools that is devoted to education on musculoskeletal health. Under the outstanding leadership of Joseph Bernstein, MD, Project 100 has worked for a decade to increase formalized instruction in musculoskeletal medicine in medical schools. Although much progress has been made there is still a gap that needs to be closed.
 
The AAMC is currently interested in redesigning the fourth year of medical school to enable a more effective transition of students into post-graduate training. Seeing this as an opportunity, the idea evolved of developing an innovative, standardized 4-8 week MSK education elective for fourth year medical students that will enter primary care residencies.  A project team under the leadership of USBJI Board member, Bruce D. Browner, an orthopaedic trauma surgeon, has been working to develop the course during the past year.
 
In addition to MSK specialists from the member organizations, we are collaborating in the design and implementation of the program with primary care clerkship coordinators and program directors and educators from general internal medicine and family medicine.  We seek to develop a curriculum, novel education material and evaluation methods. It will include teaching techniques designed to appeal to the millennial learners.
 
This endeavor parallels concern expressed by the AAMC that the fourth year of medical school requires redesign to create a more effective transition to post-graduate training. AAMC has encouraged USBJI to develop the course, and once it is implemented, said it may be able to assist with its adoption.
 
Musculoskeletal diseases are among the most common conditions patients present to healthcare providers and especially primary care providers; 30% is a frequently quoted estimate. They are major sources of pain, disability and loss of productivity. Despite this reality, primary care physicians are underprepared to respond, because education in the diagnosis and management of MSK disorders and injuries is underrepresented in undergraduate medical schools and postgraduate residency programs. This gap could be addressed by creation of a focused fourth year medical school education program designed to teach students headed for careers in primary care about the management of these problems.
 
The process of building the MS4 course will involve developing teaching tools and forging relationships that will enable us to subsequently build similar education programs for residents, nurse practitioners, physicians’ assistants, and practicing physicians.  We look forward to working with members of these specialties toward these aims.
 
A large project team was created by incorporating some USBJI Board members, individuals recommended by USBJI member organizations, direct recruitment and response to a posting made on the e-bulletin board of the Society of General Internal Medicine.  Design of the course has evolved from active on-line e-mail discussions by project team members from MSK specialties and primary care disciplines.
 
The principle idea has been the construction of a standardized ready-to-use course with materials that can be employed by the faculty at all medical schools to deliver
the course.  The initial four-week course is focused on the general approach to MSK problems. It will emphasize patient evaluation with motivated interviewing and physical examination. Common MSK problems presenting in primary care office practice will be covered in modules organized by regional skeletal anatomy. Additional modules will address major problems including: osteoporosis and fragility fractures, inflammatory arthritis, osteoarthritis, pain management, mechanical and postural problems, total joint replacement, and PCP-specialist coordination.
 
The course will employ the latest concepts in medical education, including the “flipped classroom,” with extensive use of on-line mini lectures, small discussion groups, case studies, physical examination labs for each body region and relevant clinical experiences.
 
In addition to the four week general course, two week electives will be developed for: MSK Pediatrics, MSK Emergency Medicine, Sports Medicine and Ultrasound, Geriatrics, Occupational Medicine and Employee Health.
 
Recruitment is almost completed for MSK specialists and primary care physicians who will serve as Subgroup Leaders for each anatomic and disease module. They will be responsible for working with project team members and others to define the content of each module, create the mini-lectures and case studies, design the hands-on physical examination labs for each anatomic area, and structure the clinical experiences. They will produce “owner’s manuals” and assist subsequently in “training the trainers” when the course is rolled out.
 
Evaluation method for the course, students and faculty will be developed. Strong consideration will be given to using the MSK NBME shelf exam that was created several years ago by the NBME in collaboration with a Project 100 task force. This would allow uniform national evaluation of knowledge acquisition. Clinical skills may be evaluated using objective structured clinical examinations (OSCEs).
 
To keep costs down and allow distributed production of the mini-lectures by a variety of individuals at different geographic locations, we are considering the use of the computer program Camtasia® or a similar product. Standards will be established working with the subgroup leaders to create a branded consistent appearance for the mini-lectures, case studies and associated PowerPoint slide sets, lab instructions, clinical experience designs, and owner’s manuals.  Given the existence and use of different internal electronic bulletin boards at each medical school, the MS4 MSK Course materials will probably be compiled and distributed via dedicated web site.  It is hoped that the material can be created over the next 6-9 months so the course can be field-tested in a number of medical schools and refined before general distribution.
 
In addition to providing future primary care physicians with knowledge and tools to undertake independent care of patients with MSK problems, a goal of the course will be enabling more appropriate and timely referral of patients for treatment or consultation with a variety of MSK specialists.  We hope, therefore, to work with our colleagues in primary care to improve the overall health system by more effectively coordinating care and enabling each group to assume a portion of the large burden of MSK disease in the US.  The course will be designed and distributed for international use and benefit as well.
 

American Academy of Orthopaedic Surgeons

New public service advertisement promotes the link between active families and bone health

Exercise and activity during childhood, along with a nutritious diet, are critical for building strong bones and maintaining a healthy body weight—not just in childhood, but for life. In fact, the more bone mass created during childhood and adolescence the greater the chance of preventing osteoporosis (brittle and weak bones) and related fractures later in life.

Unfortunately, video games, technology, screen time and busy schedules are resulting in fewer opportunities for exercise in today's children and adolescents.

To emphasize the need for kids to stay healthy and active, the American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America have created a new video public service advertisement, distributed to television stations throughout the U.S., that humorously features grandparents introducing various outdoor activities to their technology-focused grandson. The video is funny, but also sends an important message: Parents, grandparents and families should encourage exercise and healthy behaviors in children.
“You’re going to love your new birthday present. Are you ready?” a grandfather says as he uncovers his grandson’s eyes in the new video. “It’s a teeter totter.”

The child looks unimpressed and returns to his electronic game. Eventually, after several funny and unsuccessful attempts to introduce outdoor activities to the child, the grandparents take him to the park for a walk. The video ends with the boy and a friend on the teeter totter with the reminder: “For strong bones, activity runs in the family.” For more information, viewers are directed to OrthoInfo.org/ActiveFamilies.

“Childhood obesity is an epidemic. This campaign reminds children and adults about the importance of regular physical activity in ensuring healthy bones and joints,” said AAOS President William J. Maloney. “We’re pleased that POSNA has joined us in promoting this important message.”

“Children are more likely to be healthy and active if their parents and family are active,” said POSNA Communications Council Chair Jennifer M. Weiss, MD. “People of all ages are encouraged to spend at least 45 minutes a day engaging in physical activity. This is important for our heart and lungs, but also for our bone and muscle strength. Creating this habit early in life leads to healthier body weight, lower risk of bone problems throughout life. Active children are less likely to be obese, and obesity can lead to bone problems like slipped hips, crooked legs, and trouble healing broken bones.”

The PSA campaign complements the Academy’s new Communities in Motion event held in San Diego during the AAOS 2017 Annual Meeting, and the new online resource for physicians and patients at ANationInMotion.org/Communities. The Communities in Motion virtual park features links, according to body part, with educational materials, and animated exercises and other tips for staying healthy and injury free.



 

American Medical Society for Sports Medicine

AMSSM Launches Collaborative Research Network

In August of 2016, the American Medical Society for Sports Medicine (AMSSM) launched the AMSSM Collaborative Research Network (CRN) to further expand its research presence within the organization and develop lasting collaborations external to AMSSM. The mission of the CRN is to foster collaborative multisite research among [AMSSM] members with a goal of advancing the practice of sports medicine.  Since its inception, CRN Leadership has worked with clinical experts in many areas of sports medicine to identify priority research areas for 2017.  These areas include: Bone Health, Cardiac Screening, Concussion, Sports Specialization, and Ultrasound.  In conjunction with the announcement of these research priorities, the CRN is thrilled to announce an intramural request for proposals to be released in mid-May.  This RFP(2 years, $300K max) is open to all AMSSM members who are encouraged to connect with collaborators both within and outside of AMSSM.  The RFP is intended as seed money to provide data for major external grants to follow.  Letters of intent are due June 30th with invited full proposals due November 1st.  Any questions or comments about the CRN or the RFP can be directed to AMSSM’s Research Director, Stephanie Kliethermes at skliethermes@amssm.org.