March 2018

President's Message - Osteoporosis Treatment Crisis – 2018 Update

Osteoporosis Treatment Crisis – 2018 Update

Marc Hochberg, MD, MPH, MACP, President, USBJI

My friend and our Past-President, Dr. David Pisetsky, wrote his President’s Message on the topic of the “Osteoporosis Treatment Crisis” in October 2016. He noted that “osteoporosis care is lagging despite impressive advances in drug therapy and the recognition of the importance of diet and exercise” and raised concerns about the roles of different members of the health care team in the diagnosis and management of the patient with osteoporosis. Since the publication of his message, there have been a number of important publications about the increasing burden of osteoporosis and related fractures among the adult population in the United States; I would like to take this opportunity to review some of these data for you.

Dr. Anne Looker, formerly of the National Center for Health Statistics and the Centers for Disease Control and Prevention and one of the authors of the chapter on Osteoporosis in the Burden of Musculoskeletal Diseases (BMUS), analyzed data from the National Health and Nutrition Examination Survey (NHANES) and reported that the prevalence of osteoporosis and low bone mass increased among U.S. adults aged 50 years and above in 2013-14, the most recent two-year period with available data. Indeed, over 10 percent of adults in this age group had osteoporosis either at their hip or in their lumbar spine. The increase could not be explained by changes in body weight, smoking, dietary milk intake. In another publication, she reported that over 5 percent of U.S. adults aged 40 and above had spine fractures with the burden increasing with increasing age exceeding 10 percent in persons aged 70-79 and approaching 20 percent in persons aged 80 and above. Finally, Dr. Michael Lewiecki, a member of our advisory committee for “Fit to a T”, the USBJI Public Education program for bone health and fracture prevention, reported that the rate of hip fractures among U.S. women aged 65 and above had plateaued in the years 2013-15 ending an almost two-decade long decline resulting in over 10,000 more hip fractures than expected. It is well recognized that the occurrence of a hip fracture is associated with excess mortality, increased likelihood for nursing home admission and persistent disability among survivors in the year following the fracture.

In an attempt to address these issues, the American Society for Bone and Mineral Research, one of the USBJI founding member organizations, organized a Fracture Prevention Stakeholder Summit in July 2017 that has led to a new “Strategic Roadmap to Prevent Secondary Fractures.” The USBJI was involved in the development of the “Roadmap” and strongly endorses its recommendations. The Fit to a T Advisory Committee is revising the core material in “Fit to a T” to reflect the key messages of the “Roadmap” with greater emphasis on adults aged 65 and above with a prior fracture and informing them about treatment options including both diet, exercise, fall prevention strategies and use of FDA-approved medications that have been shown to be effective in reducing fracture risk. We anticipate publishing the updated chapter on Osteoporosis in the upcoming 4^th edition of BMUS during 2018. Finally, we look forward to continuing this dialogue with our members and other interested parties and welcome your comments via our website.

A Look at the Link between Brains and Sprains

Daniel Herman, MD, PhD, Department of Orthopaedics and Rehabilitation , University of Florida

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Imagine that you are a college football running back. You have just received the hand-off and are trying to sweep around the right end of the line. Even with a relatively common, straightforward play such as this, there are a myriad of factors to which you need to attend. You are visually scanning the field to locate the position of the linebacker mirroring your motion while trying to pay some attention to the cornerback that came free to your right. You draw upon your memory from practice to help determine how you should cut off the pulling guard’s block. The field is wet and your footing is uncertain, requiring constant assessment and adjustments of your biomechanics. Oh, and you need to do all of these tasks at the same time with as much speed as you can muster.

Sensory processing, attention, memory, motor control, reaction time, dual-tasking…things can get complicated quickly, and occasionally cause the system to break down when limited neurocognitive resources are not appropriately allocated or are lacking. In this case, your cleats bite more firmly into the ground than anticipated when you cut up field, but your focus on the linebacker’s positioning does not allow you to process this new information and make the necessary motor adjustments as quickly as needed. You feel a pop and pain in your knee, and instantly realize your season is over.

I cut my teeth as a doctoral student in the area of biomechanics related to anterior cruciate ligament injury risk and prevention, but as a MD/PhD student I realized that the masters students in my lab would be close to receiving tenure by the time I was finished with medical school, residency, and fellowship. The world of ACL injury biomechanics was going to get crowded during that time, and I realized that I would need to identify an unexplored niche to which I could apply my skills.

Inspiration came in the form of Buzz Swanik’s landmark 2007 study demonstrating that ACL injured athletes had worse pre-injury neurocognitive performance compared to matched healthy athletes. Not only could I see how I could link neurocognitive performance to neuromuscular control and injury risk, but I also saw a way to marry my training in human movement biomechanics to another burgeoning hot topic: concussions. We already know that subtle neurocognitive decrements persist beyond the point of clinical return to play guidelines, but nobody at the time had investigated whether or not that impaired athletic neuromuscular performance or injury risk.

Since this time, my research efforts have been directed towards these questions. I have had several critical points in the development of this line of research, ranging from securing a couple small research foundation grants during my residency to receiving a K12 training grant through the Rehabilitation Scientist Training Program. My investigations have shown that concussed athletes have an increased risk of lower extremity musculoskeletal injury after return to play compared to non-concussed athletes, and that these athletes demonstrate altered biomechanics associated with an increased risk of lower extremity injury extending well beyond the clinical resolution of their concussion.

One of most consistent threads throughout my development of this line of research and as an early-career investigator has been the importance of mentorship. Having excellent mentors (such as those through the USBJI Young Investigator Initiative) are absolutely crucial to the growth of any new investigator such that the extensive training and effort put forth to get to this point in our careers doesn’t “die on the vine.” I place an emphasis on the plural in this case; it is important to have a variety of relationships with people from different backgrounds and perspectives in order to successfully navigate the occasionally treacherous waters of academic development. My mentors have included physicians, neuropsychologists, physical therapists, athletic trainers, biomechanists, exercise physiologists, and a range of other clinicians and researchers. I can point to several different cases for each where their specific expertise and experience have been highly valuable and informative, which leads me to end with this bit of advice to other young investigators: If you do not have a mentorship *team* then I would submit that you have no mentors at all.

Dr. Daniel Herman is a USBJI Young Investigator Initiative participant and an assistant professor in the Department of Orthopaedics and Rehabilitation at the University of Florida. Dr. Herman maintains a research program in the area of human motion biomechanics related to sports performance, injury, and injury prevention, particularly as they relate to neurocognitive performance and concussion. His work has been recognized on multiple occasions, including with the American Orthopedic Society for Sports Medicine's O'Donaghue and Excellence in Research Awards, and the American Medical Society for Sports Medicine's NCAA Research Award.

Large Collaborative Research Initiatives are Improving the Lives of Fracture Patients

Sheila Sprague, PhD, Division of Orthopaedic Surgery Department of Surgery, McMaster University

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Dr. Sheila Sprague is an alumna of the USBJI Young Investigator Initiative. She is a clinical researcher in the Department of Surgery, at McMaster University in Hamilton, Ontario where she serves as the Associate Director of the Centre for Evidence-Based Orthopaedics (CEO). The CEO’s vision is to improve the lives of patients with musculoskeletal injuries and disorders and to be world leaders in orthopaedic surgery research.

Early in her career, Dr. Sprague has had the opportunity to contribute to some of the largest orthopaedic trauma trials conducted to date including SPRINT (n=1,200), FLOW (n=2,447), FAITH (n=1,079), and TRUST (n=501) that were conducted with CEO. The results of these trials have increased the understanding of fracture care and changed practice among orthopaedic surgeons. They have also created a new benchmark by demonstrating the feasibility of conducting large, high quality trials in orthopaedics. Building upon the momentum from these trials, Dr. Sprague now serves as a co-Principal Investigator on three new trauma trials: Aqueous-PREP (n=1,540), PREPARE (n=7,820), and SPOC-CBT (n=1,600). These trials have recently been funded by the US Department of Defence, Patient-Centred Outcomes Research Institute (PCORI), and Canadian Institutes of Health Research (CIHR). In her role as co-Principal Investigator, Dr. Sprague leads the Methods Center trial management within CEO.

Also within the CEO, Dr. Sprague leads a research program aimed at improving the lives of victims of intimate partner violence (IPV) in orthopaedic fracture patients. Briefly, Dr. Sprague’s doctorate thesis was a multinational cross-sectional study to determine the prevalence of IPV victimization in 2,344 women presenting to fracture clinics with musculoskeletal injuries. This study found a lifetime IPV prevalence of 33%, a 12-month IPV prevalence of 17%, and an acute IPV prevalence of 2%. This study was seminal in raising awareness within the orthopaedic community about the prevalence of IPV and provided the foundation for the current body of IPV research being conducted within CEO. In 2015, Dr. Sprague was awarded a CIHR Knowledge Synthesis grant to conduct a scoping review of the literature evaluating an IPV identification, assistance, or educational program within a health care setting. The scoping review resulted in 4 manuscript publications and led to a CIHR Knowledge to Action grant in 2016 to implement and evaluate an evidence-based IPV educational program. The purpose of this educational program was to empower orthopaedic surgeons and health care providers to successfully identify and assist IPV victims within their practice. The results of the evaluation demonstrate that the program increases orthopaedic surgeons’ and health care providers’ IPV-related knowledge, attitudes, beliefs, and self-reported behaviours. As a result of the success of the program, CEO personnel are working closely with the Canadian Orthopaedic Association to make the IPV educational program available to all fracture clinics across Canada.

Dr. Sprague identifies the excellent mentorship she received from multiple researchers both within CEO and beyond as having played a key role in her career development. The CEO’s faculty, well-developed infrastructure, international collaborations, and talented research team provided the ideal environment for advancing her research.

Knee Arthroscopy in Patients With Degenerative Cartilage and Meniscus Disease

James H. Lubowitz, M.D. Editor-in-Chief, Arthroscopy: The Journal of Arthroscopic and Related Surgery

Arthroscopy Association of North America (AANA)

While it is well known that arthroscopic knee surgery is not a cure for degenerative joint disease, the BMJ published a 2017 Clinical Practice Guideline asserting that arthroscopic treatment of degenerative meniscal tears is contraindicated in “nearly all patients.”¹ The position is controversial, and the purpose of this commentary is to share two publications from Arthroscopy journal that provide, in my opinion, a more fair and balanced assessment of the situation.

First, in January 2018, Steve Bollen, M.B., F.R.C.S., F.R.C.S.Edin(Orth), published “An Open Letter to the Editor of The BMJ.”² Bollen well identifies bias in the BMJ review, and presents clear evidence that, although arthroscopic knee surgery is not primarily indicated in patients with degenerative joint disease, “a carefully selected minority benefit greatly after at least 3 months of conservative treatment has failed.”²

Second, while Dr. Bollen’s argument is well referenced and supported by previously published articles, it is timely to consider a most recent article (published electronically and “in press” for 2018) by Su and colleagues from Beijing, “Comparison of Arthroscopic and Conservative Treatments for Knee Osteoarthritis: A 5-Year Retrospective Comparative Study.”³ Strengths of this study by Su et al. include evaluation of more than 350 patients with knee osteoarthritis, a minimum follow-up of 5 years, and less than 10% of patients lost to follow-up. A limitation is its retrospective study methods resulting in selection bias (comparing two groups with different prognoses, like ”apples to oranges”), where logically, the patients selected for nonoperative treatment were more likely to be managing sufficiently without arthroscopic intervention, and the patients selected for arthroscopy were coping less well with conservative management. Su et al. show that at 5 years, arthroscopy was not superior to nonoperative treatment, and the rates of patients who ultimately underwent total knee arthroplasty was similar. However, the authors show that, “arthroscopy had a greater ability to relieve symptoms at 1 and 2 years.” Su et al. conclude, “Our results suggest that arthroscopy can relieve symptoms up to 2 years without elevating the risk of arthroplasty.”

In summary, patients with degenerative meniscal tears and osteoarthritis who have substantial pain and limitation of function after nonoperative treatment may benefit from knee arthroscopy. Arthroscopy is not a cure for osteoarthritis, nor the primary treatment for degenerative meniscal tears, but practitioners who treat patients with these conditions should be aware of the latest literature in order to best counsel patients who continue to suffer from these conditions when conservative treatment is ineffective.

References
1. Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: A clinical practice guideline. BMJ 2017;357:j1982.
2. Bollen S. An open letter to the editor of The BMJ. Arthroscopy 2018;34:8-11.
3. Su X, Li C, Liao W, Liu J, Zhang H, Li J, Li Z. Comparison of arthroscopic and conservative treatments for knee osteoarthritis: A 5-year retrospective comparative study. Arthroscopy 2018;34 (in press, doi: 10.1016/j.arthro.2017.09.023. [E-pub ahead of print]). (MTF)
In 1987, a group of orthopedic surgeons seeking better access to high quality bone and other tissue came together to form the Musculoskeletal Transplant Foundation. Three decades later, this surgeon-governed, non-profit organization, now known as MTF Biologics, has evolved into the largest tissue bank in the world. It has distributed more than 8 million tissue grafts, saving and healing the lives of an estimated 6 million people worldwide.

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Sex and Gender Health Education Summit

American Medical Women's Association (AMWA)

The American Medical Women's Association will be co-sponsoring a multi-professional Sex and Gender Health Education (SGHE) Summit on April 8-10, 2018 at the University of Utah. All educators in medicine, nursing, physical therapy, dentistry, pharmacy, and other allied health professions are encouraged to attend. Limited travel grants are available that cover registration and lodging. Please visit sghesummit2018.com to learn more and to apply for a travel grant.

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MTF Biologics Advances Tissue Transplantation

MTF Biologics (MTF)

Although MTF Biologics’ work has expanded beyond the orthopedics realm, its commitment to innovation in the orthopedics sector remains strong.

Many know MTF Biologics for its large portfolio of orthopedic and sports medicine tissues including bone void fillers, DBX®, structural allograft spinal spacers, allograft tendons (soft tissue, bone-tendon-bone and pre-shaped grafts), Trinity® viable cell-based allografts, and amniotic tissues, which can act as a wound covering and anti-adhesion barrier. It also offers graft matching services for osteoarticular, meniscal, and fresh osteochondral allografts. This helps provide the best anatomically matched tissue graft for a patient and reduces operating room time by eliminating the need for extensive modifications during transplantation.

The organization has worked in partnership with surgeons to ensure that it provides the highest quality allograft tissue. MTF Biologics exceeds all industry standards tissue banks must follow and uses a unique aseptic processing method that protects tissue quality – including biomechanical integrity and biochemistry of a transplantable tissue – by minimizing the use of harsh chemicals and terminal radiation.

MTF Biologics also collaborates with clinicians and researchers around the world to advance the science of tissue transplantation. In addition to investments in its own research and development, it supports research through the Orthopaedic Research and Education Foundation and Musculoskeletal Tumor Society, and has provided more than $55 million in research grants to support promising studies, clinicians and scientists. Recently funded projects include:

Kristofer Jones, M.D., University of California, Los Angeles, “Biomechanical Evaluation of Contact Forces on Large Osteochondral Allografts: Effects of Graft Proudness, Donor Graft Sizing, and Medial-Lateral Graft Switching”

Clare Rimnac, Ph.D., Case Western Reserve University, “Is the Fatigue Life of Allograft Cortical Bone Sterilization Dose Dependent?”
Aaron James, M.D., Johns Hopkins University, “Bone Formation by Perivascular Stem Cells: Influence of Osteoporosis”

Ryan Warth, M.D., University of Texas Health Science Center-Houston, “Can We Improve Meniscal Healing in the Avascular Zone?: Fibrin Clot Augmentation with Stem Cells and Anti-Fibrotic Drugs”

Roman Eliseev, M.D., Ph.D., University of Rochester, “Improving Mitochondrial Function to Accelerate Bone Graft Healing”
Charles Hannon, M.D., Rush University, “The Influence of Amniotic Membrane and BMAC on Osteoarthritis”
Alexander Jinnah, M.D., Wake Forest University, “The Healing Potential of a Decellularized, Deoxidized Porcine Bone Scaffold”

Thomas Scharschmidt, M.D., The Ohio State University, “Tension-Induced Periosteal Expansion: A Strategy for Managing Segmental Bone Defects”

To find out more about MTF’s peer-review grant process and portfolio of life enhancing tissues, visit www.mtfbiologics.org or call 800-946-9008.

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CDC Arthritis Program

The USBJI is part of a coalition of organizations led by the Arthritis Foundation which is urging Congress to maintain funding for the Arthritis Program at the Centers for Disease Control and Prevention.

The Arthritis Program is funded under the CDC Division of Population Health and is the only federal program dedicated solely to arthritis. More than 1 in 4 adults has doctor-diagnosed arthritis and an estimated 78 million Americans will have the disease by 2040. Arthritis has a profound physical, societal, and financial impact in every state and in every Congressional district.

The overall economic burden associated with arthritis is now estimated at $300 billion annually, thanks to the public health research undertaken at the CDC Arthritis Program over the last year. This figure has more than doubled over the last decade. To put this into perspective, the annual economic cost of arthritis surpasses that of tobacco-related health effects, cancer, and diabetes.

The CDC Arthritis Program provides disease management resources to help people with arthritis better manage their symptoms and ultimately improve their health outcomes. As the country’s leading cause of disability, arthritis limits the type or amount of work for 1 out of 3 working age adults
(18–65 years) with the disease, or whether they can work at all. It also contributes to more than 750,000 hip and knee replacements every year, some of which could be avoided with proper disease management.

At the national level, the program funds organizations that have a broad impact across the country. The CDC Arthritis Program also funds the only longitudinal study dedicated to arthritis, out of the University of North Carolina at Chapel Hill. The program funds data collection that provides us with critical information about the disease, including prevalence, cost, co-morbidities, activity limitations, and uptake of physical activity and self-management programs. The program undertakes the lead work in detailing the prevalence of arthritis for the USBJI’s The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost (BMUS), a critical publication for researchers and health policy analysts.

At the state level, the program helps states implement self-management education and physical activity interventions, which are crucial for overall disease management. At present, the CDC is only able to fund 12 states (CA, KS, KY, MI, MO, MT, NY, OR, PA, RI, SC, and UT) despite the growing demand for these programs. There is a clear need for all 50 states and the District of Columbia to have Arthritis Programs.

The CDC Arthritis Program currently receives $11 million in funding. In addition to this level of funding being maintained, an additional $5 million is being requested so that the program would be able to:

Improve access and availability of proven interventions for people with arthritis by funding a total of at least 14 state health departments and funding 5 national organizations at adequate levels to disseminate effective public health approaches through large systems of care, worksites, and national networks with local sites for implementation.
Improve access to, and infrastructure and support for, evidence-based interventions for people with arthritis by identifying or developing effective new interventions and/or by providing limited support to intervention developers to maintain and scale the growth of proven interventions.
Provide additional support to the Johnston County Osteoarthritis Project, a one-of-a-kind longitudinal study that documents the prevalence, incidence and risk factors associated with the occurrence and progression of hip and knee osteoarthritis - the most common and disabling types of arthritis.
Build upon the CDC Public Health Agenda for Psoriasis and Psoriatic Arthritis to advance self-management interventions and implement the next generation of public health research for psoriatic arthritis.
Advance the cause of the National Public Health Agenda for Osteoarthritis to elevate osteoarthritis as a national health priority by leveraging public and private funding through the Osteoarthritis Action Alliance (OAAA).
Invest in public health research to further address arthritis and other comorbidities

There is significant demand for these types of programs. In 2015, the Osteoarthritis Action Alliance
(OAAA) launched a small grant program focused on increasing access to physical activity levels among people with arthritis. Fifty-one letters of intent were submitted from 21 states; in 2016 there were 89 letters of intent submitted from 39 states, indicating a high level of interest in organizational efforts to help people manage their arthritis. To date, the OAAA has awarded mini-grants to a total of 34 organizations across 23 states. A stronger federal investment in the Arthritis Program can help meet this demand.

People can manage and reduce the symptoms of arthritis through self-management programs, physical activity, and weight loss, but effective interventions for arthritis are drastically underutilized. The CDC Arthritis Program can provide leadership, technical expertise, and cutting-edge research to improve the health and well-being of people with arthritis.

USBJI Member societies concerned with arthritis are invited to support the effort to maintain and to increase funding for the CDC Arthritis Program. (Contact Vincent Pacileo, Arthritis Foundation, vpacileo@arthritis.org

New AUC on Management of DDH in Infants

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors has approved new Appropriate Use Criteria (AUC) for Management of Developmental Dysplasia of the Hip (DDH) in Infants up to Six Months of Age. This AUC is the first to provide two versions of an online diagnostic tool for management of DDH: one customized for generalists referring physicians, and one customized for orthopaedic specialists. The new AUC supports an existing AAOS Clinical Practice Guideline, "Management of Detection and Nonoperative Management of Pediatric DDH in Infants Up to Six Months of Age."

View "Management of DDH for Orthopaedic Specialists"…
View "Management of DDH for Generalists and Referring Physicians"…
View all AAOS AUCs…

Public Comments Sought on Management of Hip Fractures in the Elderly Performance Measure

A quality measure developed by the AAOS related to the timing of surgical intervention of hip fractures in the elderly is entering the public commentary stage. Public comments on the guideline will be accepted through Friday, March 30, 2018. For more information, the necessary materials, and to provide comments, please contact Mary DeMars, at: demars@aaos.org

Osteoarthritis Action Alliance – Recent Achievements and Announcements

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The USBJI is a member and active participant in the Osteoarthritis Action Alliance (OAAA), led by former USBJI Board member Dr. Leigh Callahan of the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill. The Chronic Osteoarthritis Management Initiative (COAMI) which the USBJI founded to address the need for a paradigm change in the approach to managing Osteoarthritis is now incorporated into the OAAA.
Recent webinars for the public and healthcare professionals:

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The OAAA participated in a #Rheumchat twitter chat on Arthritis 101: What Patients Need To Know, which took place in January, and America Walks #safewalks chat in February, and in conjunction with National Public Health Week, the 1 billion steps challenge.

The OAAA’s Weight Management task group presented a symposium at Obesity Week on Beyond Energy Expenditure: The Role of Musculoskeletal Health in Prescribing Exercise to Children with Obesity, at the American Public Health Association (APHA) Annual Meeting on Expanding Access to Arthritis Appropriate Evidence Based Interventions in Local Communities, and at the American College of Rheumatology (ACR) Annual Meeting, on Engaging with Community Organizations to Promote Physical Activity Interventions.
The OAAA has created a new infographic with the American Council on Exercise on the benefits and barriers to physical activity for adults with arthritis. The primary purpose of the infographic is to encourage referral to the OAAA online Physical Activity Implementation Guide. Several members of the OAAA Lower Limb Injury Prevention task group co-authored the National Athletic Trainers’ Association (NATA) position statement on ACL injury prevention released in January 2017, and noted elsewhere in this newsletter. Based largely on OAAA injury prevention resources and awareness efforts, NATA added new osteoarthritis resources to their Chronic Injuries and Conditions page.

Recent research on OA includes The Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial by Krebs, E.E. et al. published in the Journal of the American Medical Association. The OAAA maintains a listing of The Latest in Osteoarthritis Research.

MSK-Ed - Musculoskeletal Education for Primary Care Providers: Broadening the MS4 Initiative

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MSK-Ed is a new series of programs being developed by the US Bone and Joint Initiative (USBJI). The goal is provide comprehensive MSK education courses for primary providers to better enable them to prevent, diagnose, directly manage, and appropriately refer MSK disorders and injuries. The modules will be designed for use by individuals and multispecialty teams from relevant disciplines including medicine, nursing, and physicians assistants. The central on-line core of the education material is being fashioned to provide a common base of essential knowledge, skills and coordination for all levels: students, post-graduate trainees and practicing providers.

The programs will employ “flipped classroom” teaching and other innovative techniques, with high definition on-line video mini-lectures designed for independent synchronous or asynchronous viewing. The programs will be adaptable for both problem-based learning and team-based learning.

In addition to the on-line components, classroom discussion groups and structured case studies, physical examination and procedure laboratories, and clinical experiences will be used in some programs to further enhance the provider capabilities. A variety of novel assessment methods will be used to confirm acquisition of knowledge and competencies.

MSK Fourth Year Medical School Elective-Initial Focus
USBJI has worked for a decade with some success to increase the portion of medical school curricula that are dedicated to MSK education under Project 100, but there is still a need for more improvement. The deficit and partial improvement of MSK education has been most extensively studied in medical students (see references in addendum), but a similar problem exists in the education of nurses and physicians’ assistants. To develop the MSK-Ed course material and structure we have focused initially on designing an MSK Fourth Year Medical School Elective. The plan parallels the AAMC’s current interest in redesigning the fourth year of medical school to be more valuable for transition to postgraduate training and practice, and they have offered to help publicize the program once it’s implemented.

On-line Material Development
The team leaders who have agreed to build the on-line mini lectures and case presentations for the eighteen segments of the course met at Duke University School of Medicine on September 16, 2017 to discuss course development. They are currently fleshing out the content of the min-lectures outlined in the bullet lists they have created and creating the case studies A number of options are being explored to transmit the material over the inter-net using open access or fee based proprietary platforms.

DukeAHEAD Project
A pilot study at Duke University Schools of Medicine and Nursing funded by a modest educational grant (DukeAHEAD Grant) will allow analysis of the knowledge acquisition of groups of medical, nursing and PA students, and practicing PCPs who have viewed high definition MSK-Ed on-line mini-lectures. The groups will also provide feedback on video mini-lecture design before scaling the course up for national distribution. They will also serve as focus groups to explore the interest and feasibility of electives in professional schools, CME and CNE programs.

Business Arrangements and Oversight
Bruce Browner, Paul Ullucci, John Ventura and Toby King have collaborated to draft a business plan for the project—an important step to enable project management and fund raising. An MSK-Ed Steering Committee lead by Bruce Browner, including Matthew Dobbs, John Ventura, Jon Kirschner, Amye Leong, Paul Ullucci, Michael McBrayer, and Toby King has been assembled to oversee the project. They have held an initial conference call.

Health System Improvement Benefit and Future Program Expansion
The idea of improving the delivery of MSK patient care by educating the next generation of primary care physicians is very appealing to all. We have an opportunity to adjust the health care system to enable the primary care providers to undertake an essential share of the burden of MSK prevention and care and to enable better coordination with specialists. The lessons learned with the pilot medical school program will enable us to expand the program to other disciplines and spread the benefit to other countries that share the challenge of educating primary care providers to assume a large MSK burden

Future Programs

PCP CME Course, Nurse & NP CNE Course, Internal Medicine Residents Course, and International Education Programs.

Note

If you are interested in serving ad a local Coordinator at your medical school to apply for and implement am MSK-Ed elective in the fourth year of medical school or to use the MSK-Ed educational material in existing medical school courses,
Please contact Bruce D. Browner, MD, MHCM, MSK-Ed Project Leader at bruce.browner@duke.edu.

Joan McGowan, PhD, Director, Division of Musculoskeletal Diseases, NIAMS, NIH to Retire

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Dr. McGowan, Director of the Division of Musculoskeletal Diseases at the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health (NIH) is to retire in April. The NIH liaison to the USBJI Board since 2010, Dr. McGowan organized meetings at the NIH at the beginning of the Bone and Joint Decade to determine the direction the U.S. should take to raise the priority of musculoskeletal health, which affect one in two American adults and hundreds of thousands of children. These meetings brought together representatives of musculoskeletal patient advocacy organizations and the broad range of specialty societies treating MSK disorders as a collaborative effort. These meetings resulted in the focus on building the pipeline of funded MSK investigators through the Young Investigator Initiative of the USBJI, which has resulted in more than 220 new funded MSK investigators undertaking more than 1,300 MSK research studies, and Project 100, an initiative to increase instruction in MSK medicine at medical schools. Other programs broadening the effort to raise awareness and the priority of MSK health followed.

Dr. McGowan has served as director of the Bone Diseases Program, overseeing a broad portfolio of clinical research on osteoporosis and related bone disorders. She has been very active in bone health and women’s health issues at NIH, including serving as a project officer for the Women’s Health Initiative. She has co-chaired the federal working group on bone diseases, which develops and fosters collaborative activities across government agencies in bone diseases.

McGowan served as senior scientific editor of the Surgeon General’s Report on Bone Health and Osteoporosis, released on World Osteoporosis Day, established by the Bone and Joint Decade, on October 20, 2004. Recently she has worked with the USBJI Board to craft its Strategic Plan to cover the period June 2018 to June 2021. Before joining NIH, McGowan was a faculty member at Harvard Medical School and Massachusetts General Hospital. She received her master’s degree in nutritional sciences at Cornell University and her doctorate in biomedical science at Brown University.

The USBJI thanks Dr. McGowan for all her contributions to the musculoskeletal community during her noteworthy career, and especially to the Bone and Joint Decade, its continuing work and accomplishments.

Critical Second Fracture Prevention Initiative

The USBJI strongly supports the American Society for Bone and Mineral Research’s (“ASBMR”) Call to Action to Address the Crisis in the Treatment of Osteoporosis, issued in 2016. The year-on-year decline in the number of fractures due to osteoporosis which was achieved over the past decade levelled off in the most recent years, and the number are believed to be increasing again. At the same time the number of DXA screening tests for osteoporotic bone, a leading indicator for fracture, have dropped, as well as the number of prescriptions for medications to improve bone strength and so prevent fractures. As a direct outcome of the call to action, a Stakeholder Summit was held last year to begin the development of a Strategic Roadmap to Prevent Secondary Fractures. The roadmap places the greatest urgency on those who have already sustained a fracture due to osteoporosis and are thus at highest risk of more fractures.

ASBMR is now in the process of translating the Strategic Roadmap into a specific and detailed Action Plan to be implemented in order to achieve the goal of substantially reducing secondary fractures, and has engaged the Center for Medical Technology Policy (“CMTP”), an independent 501(c)(3) non-profit committed to improving clinical evidence for decision making, to assist in crafting the Action Plan.

The USBJI is offering its unique perspective to help guide this effort, as a body with representatives from all stakeholder groups that will be tasked with discussing and deciding essential issues such as top priorities, specific measurable goals to aim for, primary messages, etc.

Development of the Strategic Roadmap and Action Plan is one of ASBMR’s highest priorities which believes holds great promise for improving patient care and preventing secondary fractures, as well as for providing a solid base for future prevention efforts.

A recent article, A Perfect Storm for Broken Bones by Jane Brody in the New York Times describes this issue.

Help Your Community Raise Awareness About Bone and Joint Health

Spring is an excellent time to educate patients and their family, friends and support networks on how to manage and take control of their bone and joint health. The USBJI works with communities to raise awareness and understanding of the advances that have and continue to be made to lessen pain, improve mobility, and restore function for those who live with bone and joint conditions and pain through the Experts in Arthritis and Fit to a T programs.

Experts in Arthritis is a free patient education program for people with arthritis and people who care about them. Arthritis and other rheumatic conditions are the second most common musculoskeletal disease among adults in America. The program offers people with arthritis the opportunity to be better informed about current scientific evidence and management strategies in the treatment and care of osteoarthritis, rheumatoid arthritis, and juvenile arthritis. Other forms of arthritis can be incorporated, based on need.

Fit to a T is a free patient education program to educate both men and women about fracture prevention, assessing their risk for fracture and osteoporosis, and how to prevent bone loss and a fragility fracture, particularly secondary fractures. This education program is called “Fit to a T” because the T-score is the measure of a person’s bone density and susceptibility to fracture.

Help patients take control of their bone and joint health when you present or host these free public education programs on arthritis and/or fracture prevention and osteoporosis. Each program features a PowerPoint presentation, handout materials and a question and answer period. All materials are supplied free of charge and USBJI will work with you to promote program sessions and provide planning support.

Visit www.ControlArthrits.org or www.Fit2T.org to learn more and to view entertaining whiteboard videos, available in English and Spanish, that encapsulate the messages for each program. Share these videos by adding the links to wellness pages and download to share in your community to encourage healthy lifestyle changes and to raise awareness about bone and joint health.

Call for Applications -July 15 Deadline - Young Investigator Initiative Grant Mentoring and Career Development Program

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The next deadline for young investigators to apply for the Young Investigator Initiative Grant Mentoring and Career Development Program is July 15, 2018.

The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are dedicated to increasing research of musculoskeletal diseases. To keep pace with the high and increasing burden of these diseases, a higher level of research performed by young investigators in the musculoskeletal diseases is required, and future levels of research assured. This is particularly important given the current environment for research funding, and academic careers. In response, the Young Investigator Initiative is a grant mentoring and career development program providing early-career investigators an opportunity to work with experienced researchers in our field to assist them in securing funding and other survival skills required for pursuing an academic career.

To date 220 participants (55%) have successfully obtained $317 million in grants for 1,300 new musculoskeletal research studies. Participants consider this program instrumental to their success. They rate highly the one-on-one mentoring with experienced researchers, the opportunity for inter-disciplinary and peer-to-peer exchange, and collaborations established during workshops.

This grant mentoring and career development program is open to promising junior faculty, senior fellows or post-doctoral researchers nominated by their department or division chairs seeking to pursue a career in clinical or basic research. It is also open to senior fellows or residents that are doing research and have a faculty appointment in place or confirmed. Basic and clinical investigators, without or with training awards, are invited to apply. Investigators selected to take part in the program attend two workshops, 12-18 months apart, and work with faculty between workshops to develop their grant applications. The Fall 2018 workshop is scheduled to take place on November 9-11, 2018, in Toronto, Ontario. The unique aspect of this program is the opportunity for attendees to maintain a relationship with a mentor until their application is funded.

For more about the program and detailed application instructions, please refer to www.usbji.org/programs/yii.

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