USBJI April 2019

Preventing Musculoskeletal Injuries by Reducing Firearm Injuries

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

The burden of musculoskeletal (MSK) injuries was reviewed in the 3^rd edition of the Burden of Musculoskeletal Diseases (BMUS, 2014) by Andrew Pollak, MD. This chapter is being updated by the Orthopaedic Trauma Association for the 4^th edition. It is currently being reviewed so will be released soon (www.boneandjointburden.org).  While falls were noted to be the most common cause of MSK injuries, “civilian interpersonal violence” was listed as another cause, although no cause-specific data were included.

The American College of Surgeons Committee on Trauma hosted 42 professional medical and injury prevention organizations and the American Bar Association in February 2019 for the first-ever Medical Summit on Firearm Injury Prevention that focused on reducing deaths, injuries, and disabilities from firearms. The attendees met to foster an inclusive and collegial dialogue on how to work together to identify opportunities for the medical community to reach a consensus-based, apolitical approach to firearm injury prevention focused on understanding and addressing the root causes of firearm violence while making firearm ownership as safe as possible.

As a practicing internist and rheumatologist, I am familiar with the American College of Physician’s Position Paper on reducing firearm injuries that was updated in 2018 (Butkus R, et al: Ann Intern Med 2018; 169(10):704-707. The College recommended a public health approach to firearms-related violence and the prevention of firearm injuries in part through the development of coalitions among health professionals and injury prevention groups, among others.

Furthermore, as a resident of Baltimore, Maryland, I live in the U.S. city with the highest homicide rate among cities with a population greater than 500,000 persons.

At the most recent meeting of the USBJI Board of Directors, Dr. Bruce Browner, Secretary, USBJI, brought forward a motion that “The USBJI should consider the issue of Firearm Injury Prevention and join other medical groups in advocating for a consensus driven, incremental, nonpolitical public health approach to address the national epidemic of gun violence.”

I am pleased to report to the readership of the Newsletter that the Board unanimously voted to endorse this motion. They did, however, urge that we focus on musculoskeletal injuries resulting from firearm injuries, which can result in lifelong disability, so that our concerns and efforts are closely aligned with the USBJI’s mission.

We will join coalitions with other professional organizations towards supporting and implementing a public health approach to firearm-related MSK injuries and attempt to include cause-specific data, when available, in future editions of BMUS.

When we think about young adults, we tend to visualize people in good health with a vibrant, active lifestyle. We don’t often think about the difficulties faced by young people who live with chronic disabling health conditions and often lack the knowledge to seek support as they enter the labor market. This lack of awareness may have a significant impact on those starting their career with a chronic disease or disability that has no visible signs or symptoms, or is characterized by symptoms that fluctuate in severity such as arthritis or depression.
 
My research, based at the Institute for Work & Health and the University of Toronto, examines the employment experiences of young people living with chronic episodic health conditions and the challenges they face accessing workplace supports. I take a mixed-methods research approach and integrate diverse disciplines (e.g., population health, social policy and occupational health) to my research.  
 
A body of research indicates that young adulthood is a critical transitional period where a person exits educational roles, enters paid work and endeavours to advance within their career. My research has found that young adults with disabling health conditions often report challenges with employment, and may require workplace supports that can be tailored to their needs to encourage labor market engagement.
 
In a recent qualitative study of young people with juvenile arthritis and lupus, I found that being at an early career phase was related to a reluctance in requesting assistance or asking for help out of fear of losing their jobs or limiting opportunities for career advancement. As one young adult study participant described it: “I think there’s always the misconception that people don’t get impairments until later in life. And so that can always be something very difficult either to convey to your employer or to your colleagues, who may think you’re getting special treatment or you’re just a big complainer.”
 
My research has also shown that young adults with chronic disabling health conditions face a gap with regards to the workplace supports that they most need. This gap can be exacerbated when their conditions are episodic and invisible. By providing flexible strategies and solutions, employers and policy-makers can play a critical role in helping young adults living with health conditions find employment and thrive in their working lives. The impact can be important not only for labor market activity, but for quality of life.
 
More recently, with funding from an Arthritis Society (Canada) New Investigator Operating Grant, I am leading a longitudinal study to examine the role of workplace policies and practices in preventing and managing work disability of young adults with rheumatic disease as they transition into the world of work. Through active involvement of consumer groups and employers, findings from my study will contribute to a better understanding of how organizations can contribute to improvements in the health, productivity and quality of life of people living rheumatic disease.
 
In developing my program of research, I have had tremendous mentorship from senior researchers at the Institute for Work & Health, who have provided in-depth feedback on my grant submission. Similarly, the U.S. Bone and Joint Initiative (USBJI) Young Investigator Initiative has provided critical insights and tips which I have integrated when developing high quality and competitive funding applications. I often find myself flipping through my USBJI notes as I write a research protocol. Learning from those who have experienced academic success (and sometimes failure) has been invaluable to my career development.
 
One of the biggest challenges I have faced as an early career researcher has been to navigate the increasingly competitive funding landscape. As grants become more challenging to obtain, I have developed strategies for proposing creative and novel research studies that will catch the eye of a peer reviewer. I have also learned to integrate the critiques from unsuccessful applications into the design of new and improved grant applications. Importantly, I have found that by working with a range of knowledge users (e.g., consumers, policy-makers and clinicians) at all phases of the research process, I am able to produce research findings that are utilized and have social impact.

The Association of Rheumatology Health Professionals (ARHP), a membership division of the American College of Rheumatology (ACR), has changed its name.
 
Reflecting the diversity of its 22+ different types of rheumatology professionals, the Association of Rheumatology Professionals (ARP); the Interprofessional Division of ACR – is the only organization serving the needs of the entire rheumatology community.
 
The collective contribution of the interprofessional team is essential to improving the health of people living with chronic conditions. Who else is better positioned to represent the professional needs other than ACR and that of the ARP? Together, we are providing the best practices in rheumatologic care in order to improve healthcare for Americans living with rheumatic diseases. Hence, there are some exciting initiatives on the horizon to ensure the availability of rheumatology specific training and a diverse workforce to meet the needs of patients.
 
Rheumatology’s Workforce Shortage – As the US faces an estimated 91 million Americans with rheumatic or musculoskeletal disease, the 2030 projections about the limited future supply and broad demand of rheumatologists will have broad implications to the training, recruitment, practice management, and funding to the specialty, impacting patient access. Given the anticipated shortfall of rheumatologists, it is essential to have a qualified team of NPs/PAs and other rheumatology professionals ready to meet patient needs. For members of the interprofessional team, introduction to the field is not something gained during training. Many NP’s, PA’s and others are unaware the specialty offers study in systemic disease that with medical advances, and care from other specialists such as PTs, OTs, the team is able to see very ill patients make progress over time. Working with a team of professionals to help patients is so rewarding but the gratitude expressed by those patients is lifelong. Therefore, the ARP and the ACR are working to ensure appropriate availability of resources such as training, funding, and a home for rheumatology professionals.

Training & Education:

• Online Educational Portfolio – ARP currently provides valuable educational resources to the interprofessional team along every phase of their career trajectory. Each educational resource is intentionally developed to allow rheumatology professionals to excel in our specialty. Members enjoy deep discounts in addition to complimentary education such as our eBytes, 30 minutes of online education dedicated to varying topics, as well as research webinars touching on issues such as Multidimensional Assessment of Pain. 
• NP/PA Webinar Series and Associated Toolkits – Proper rheumatology onboarding is essential in retaining qualified professionals. ARP’s NP/PA Webinar Series serves as a valuable resource from both the perspective of the NP/PA as well as the employer. This series unlocks all the answers to what works and what doesn’t. Unique to this educational offering is the accompaniment of toolkits for use in the practice as reference guides to ensure successful onboarding and retention procedures are in place.
•  The Training Rheum – In partnership with the American Academy of  PAs, the ACR through its ARP and Workforce & Training Divisions, is developing “The Training Rheum - Atlanta and Austin”. The Training Rheum will provide PAs and NPs with a well-rounded foundation on the essential rheumatology topics over the course of two and a half days. It is perfect for those new to or those transitioning into rheumatology.  
• Grants/Awards – Through our Rheumatology Research Foundation, ARP is committed to funding rheumatology education, training, and research that will improve treatments for people with rheumatic diseases. Only members are eligible to apply for our:
  • Clinical Scholar Educator Award
  • Health Professional Online Education Grant
  • Innovative Research Award
  • Mentored NP/PA Award for Workplace Expansion
  • Scientist Development Award

ARP’s complement of online education, its newest webinar series and associated toolkits, The Training Rheum hands-on boot camp, and the multiple Rheumatology Research Foundation training grants, work to ensure that proper training is available as well as training funds.

“Improving Lives Together” Membership Campaign – We invite rheumatology professionals to JOIN ARP as one voice, working together. Through the campaign, ARP will showcase the voices of rheumatology professionals across the US who represent actual interprofessional teams, working together along with our ACR physicians. This campaign provides a sneak peek into our member’s professional lives to tell their story of how ARP and the value of the College delivers on our brand promise. As a show of appreciation by patients, they are also lending their voices to the campaign, highlighting the quality care they receive from the interprofessional team who are integral to creating a positive treatment community for those with rheumatic and musculoskeletal disease.
 
With the goal of providing quality care for patients, these strategic initiatives allow ARP to continue its longstanding history of developing high quality clinical practice tools and innovative educational products. Through these and other concerted efforts of the entire College, addressing the workforce shortage continues to be a priority as we focus on Improving Lives Together!
 
If you are a rheumatology professional, we again invite you to Join ARP.
 
We are there for you, so you can be there for your patients.
 
Visit us at www.rheumatology.org

The American Orthopaedic Foot & Ankle Society (AOFAS) released a new position statement supporting the use of validated Patient-Reported Outcomes Measures (PROM), or data collected directly from patients regarding their perceived health, functional status, and quality of life. Used in conjunction with clinical measures, PROMs provide valuable insight into the patient perspective of foot and ankle treatment outcomes.
 
Harold B. Kitaoka, MD, chair of the AOFAS Research Committee explains, “Although it is not possible to recommend a single instrument to collect quality orthopaedic data as the selection is dependent upon several factors, the position statement evaluates various options and serves as a guideline for researchers, surgeons, and other medical practitioners in foot and ankle orthopaedic surgery.”
 
The orthopaedic community has placed increased emphasis on PROMs to advance how we measure and compare treatments and develop evidence-based guidelines. The AOFAS position statement asserts that PROMs are crucial for demonstrating the effectiveness of healthcare interventions and encouraging patient-centered care.
 
"We are in the era of evolving healthcare delivery,” said Phinit Phisitkul, MD, chair of the AOFAS Evidence-Based Medicine Committee and foot and ankle orthopaedic surgeon at Tri-State Specialists in Iowa. “Nothing stands up for our practice like good results from patient-reported outcomes."
 
To read the position statement, visit aofas.org/healthpolicy. A podcast discussing the statement is available through Foot & Ankle International, the official journal of the AOFAS.

March was National Athletic Training Month, and the National Athletic Trainers’ Association (NATA) wants the world to know that “ATs Are Health Care,” whether we are enhancing performance, preventing sudden death in sports or treating musculoskeletal injuries suffered by the physically active! With more than 70 percent of all emergency department (ED) visits either inappropriate or avoidable,¹ athletic trainers reduce the burden on the ED by managing the emergent needs of the physically active and reducing unnecessary transport to the ED.

NATA and its 45,000-plus members are actively working on the athletic field, in the clinic/hospital and in the research lab, among other places, to improve musculoskeletal health for all those who are physically active. Athletic trainers work with physically active individuals of all ages, in order to prevent musculoskeletal injuries as well as provide emergent and long-term care from those suffering from musculoskeletal injuries. Athletic trainers are researching all aspects of musculoskeletal health, from the biological markers for concussion to national epidemiological studies on the impact of sports injuries on high school and collegiate athletes. Athletic trainers have an enormous scope of practice, which includes treating the pediatric through geriatric patient population whether they are in a school, college or professional sports organization. Athletic trainers also work with the industrial, performing arts, tactical and combat athlete. NATA research priorities have been nicely summarized by the NATA Research & Education Foundation, and can be found at https://natafoundation.org/research/atresearchagenda / as well as in an article published by Eberman et al².

The Journal of Athletic Training is one NATA’s many publications. It is indexed in Pubmed and has an impact factor of 2.319. In the past few months, JAT has published numerous articles on the prevalence of injuries in various sports at the high school level.^3-12

NATA has more than 25 different position statements designed to prevent or address various musculoskeletal injuries. It has also partnered with other musculoskeletal stakeholders to develop consensus statements. These publications are the product of numerous athletic trainers working throughout the country and was sponsored by NATA. A study looking at injuries at the collegiate level, which includes all four military academies, is also underway and partially sponsored by NATA. These large epidemiological studies demonstrate NATA’s commitment to protecting and preserving the musculoskeletal health of today’s high school and college athletes. Similarly, NATA and its members lead the way in research in the area of concussion and sudden death in the athlete.¹³ NATA and its partner organizations are currently funding the study of all sports-related sudden deaths, including cardiac sudden death, heat-related deaths and catastrophic head and spinal injuries.

In 2017, NATA launched At Your Own Risk, a public advocacy campaign designed to educate patients, parents, school administrators, employers and legislators on the important role athletic trainers play. The website, www.AtYourOwnRisk.org, is designed to educate and provide resources for people to act and advocate for athletic trainers.

Athletic trainers continue to push for the prevention, early recognition and prompt treatment of all injuries of the physically active including the athlete, performer, industrial worker and tactical and combat athlete.
 
References
 
1.         Review BH. https://www.beckershospitalreview.com/patient-flow/study-71-of-ed-visits-unnecessary-avoidable.html. 2013. Accessed 3/21/19, 2019.
2.         Eberman LE, Walker SE, Floyd RT, et al. The Prioritized Research Agenda for the Athletic Training Profession: A Report from the Strategic Alliance Research Agenda Task Force. Journal of Athletic Training. 2019.
3.         DiStefano LJ, Dann CL, Chang CJ, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls' Soccer (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Women's Soccer (2004–2005 Through 2013–2014). Journal of Athletic Training. 2018;53(9):880-892.
4.         Kerr ZY, Gregory AJ, Wosmek J, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls' Volleyball (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Women's Volleyball (2004–2005 Through 2013–2014). Journal of Athletic Training. 2018;53(10):926-937.
5.         Kerr ZY, Putukian M, Chang CJ, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Soccer (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Men's Soccer (2004–2005 Through 2013–2014). Journal of Athletic Training. 2018;53(9):893-905.
6.         Kroshus E, Utter AC, Pierpoint LA, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Wrestling (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Men's Wrestling (2004–2005 Through 2013–2014). Journal of Athletic Training. 2018;53(12):1143-1155.
7.         Li T, Norcross MF, Johnson ST, Koester MC. Cost-Benefit of Hiring Athletic Trainers in Oregon High Schools From 2011–2014. Journal of Athletic Training. 2018.
8.         Lynall RC, Gardner EC, Paolucci J, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls' Field Hockey (2008–2009 Through 2013–2014) and National Collegiate Athletic Association Women's Field Hockey (2004–2005 Through 2013–2014). Journal of Athletic Training. 2018;53(10):938-949.
9.         Lynall RC, Mihalik JP, Pierpoint LA, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Ice Hockey (2008–2009 Through 2013–2014) and National Collegiate Athletic Association Men's and Women's Ice Hockey (2004–2005 Through 2013–2014). Journal of Athletic Training. 2018;53(12):1129-1142.
10.       Pierpoint LA, Caswell SV, Walker N, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Girls' Lacrosse (2008–2009 Through 2013–2014) and National Collegiate Athletic Association Women's Lacrosse (2004–2005 Through 2013–2014). Journal of Athletic Training. 2019;54(1):42-54.
11.       Pierpoint LA, Lincoln AE, Walker N, et al. The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Lacrosse (2008–2009 Through 2013–2014) and National Collegiate Athletic Association Men's Lacrosse (2004–2005 Through 2013–2014). Journal of Athletic Training. 2019;54(1):30-41.
12.       Scarneo SE, Kerr ZY, Kroshus E, et al. The Socioecological Framework: A Multifaceted Approach to Preventing Sport-Related Deaths in High School Sports. Journal of Athletic Training. 2019.
13.       Dompier TP, Kucera KL, Drezner J, Casa DJ, Register-Mihalik J, Guskiewicz KM. Sudden Death and Catastrophic Injury Reporting: A Call to Action for Athletic Trainers. Journal of Athletic Training. 2019.

SRS is proud to announce it has formally initiated the first directed-research initiative in its history by partnering with the non-profit research entity International Spine Study Group Foundation (ISSGF) and five industry partners (Globus Medical, K2 Medical, Medtronic, Nuvasive, Zimmer-Biomet) to support continuation of the Adult Symptomatic Lumbar Scoliosis (ASLS) study.

The ASLS study is a prospective multicenter trial designed to compare the outcomes of operative vs. nonoperative treatment for adult patients (40-80 years of age) with symptomatic lumbar scoliosis.

Patient outcomes are evaluated using standardized patient-reported outcome measures (Scoliosis Research Society questionnaire [SRS-22], Oswestry Disability Index [ODI], and NIH developed Patient-Reported Outcome Measurement Information System [PROMIS] Computer Adapted Testing [CAT] measures), functional testing (treadmill test), complications associated with each treatment, and costs of each treatment.

The first portion of the ASLS study (ASLS I; initiated in 2009) was a NIH-funded study that evaluated the minimum two-year treatment outcomes of randomized (RC) and observational cohorts (OC). Evaluation of ASLS I data using as-treated analysis of the RC and OC combined revealed superior outcomes for operative over nonoperative treatment. The operative cohort demonstrated improvements in SRS-22 and ODI scores at 2-year follow-up, while the nonoperative cohort demonstrated no improvements, with an overall study follow-up rate of 89.5%. These findings of the as-treated analysis have recently been published in the Journal of Bone and Joint Surgery .

High crossover in the randomized cohorts from nonoperative to operative treatment precluded conclusion based on RC intent-to-treat alone. MCID analysis of the RC favored operative over nonoperative treatment. Seventy percent of patients initially randomized to nonoperative treatment crossed to operative treatment in the RC. These crossover patients who received operative treatment (despite initial randomization to nonoperative treatment) were more severely disabled prior to treatment (including worse pre-treatment SRS-22 and ODI scores), and had better post-treatment outcome scores than patients who adhered to nonoperative treatment randomization. In the combined cohorts, crossover was less than 10%.

Despite the findings of the as-treated analysis, the NIH opted not to fund phase two of the ASLS study (ASLS II), which is long-term follow-up (minimum 7 years) of ASLS study patients. We recently submitted a cost-benefit analysis to Spine. At 4- and 5-year follow-up, operative is more cost effective (based on ICER, cost-to-benefit ratio) than nonoperative treatment.

The SRS recognizes the importance of the ASLS study. There currently is no long-term multicenter, prospective outcome data for adult patients treated for spinal deformity. Consequently, patient-reported outcome, functional testing, economic, and complications data that will be provided by ASLS II are ground-breaking and represent a rich and unique dataset that will provide important information as to how to best treat adult spine deformity patients with symptomatic lumbar scoliosis.

The research initiative partnership between the SRS, ISSGF, and our corporate sponsors will allow ASLS II to be funded to completion. In-depth analyses are currently underway in conjunction with ISSGF evaluating cost-benefit ratios of operative vs. nonoperative care, the impact of opiates upon patient outcomes, and the disease burden of lumbar scoliosis. These important data are germane to the mission of the SRS. We look forward to providing research updates from this important effort so that together we can continue to improve patient care for adults with spinal deformity.

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The USBJI is promoting two activities in May for National Arthritis Month, and National Osteoporosis Month.

Campaign described above, but with particular emphasis on arthritis and on osteoporosis during May. Email usbji@affinity-strategies.com with health policy improvements which are needed to improve life for people with arthritis, and to prevent osteoporotic fractures.

These could be about * access to care, * access to medications such as step therapy, * the need for community-based prevention education, * workplace concerns, * lack of concern over care for under-represented populations, or sufficient attention to disparities in healthcare delivery, * affordability, *more funding for research, *clinical trial participation.  

We look forward to hearing from you!
 

Experts in Arthritis                          Fit to a T

Experts in Arthritis is a  free patient education program for people with arthritis and people who care about them. The program offers people with arthritis the opportunity to be better informed about management and treatment strategies in rheumatoid arthritis, osteoarthritis, and juvenile arthritis. To request a session in your community, visit www.ControlArthritis.org and submit a request/registration form. 

Fit to a T  educates men and women about fracture prevention. It covers risk factors for fracture and osteoporosis, how to prevent bone loss and thus osteoporotic fractures, particularly secondary fractures. Fall prevention is an important component. These one-hour sessions come with ready-to-use materials and logistical support, provided free of charge.

 
Take this opportunity to register for a live session today! Visit www.ControlArthritis.org or Fit2T.org.

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GMUSC, of which the USBJI is the US arm, has begun organization for a conference to be held in Geneva in 2020. The conference will be aligned with the WHO’s announcement that year of the Decade on Healthy Aging, and its new major indicator, “healthy life years” (HLYs).  The conference will be designed to map out priorities for raising the priority of musculoskeletal health in the next decade, and seeks to engage the next generation of individuals who can lead these activities. The USBJI would like to propose individuals from the US to participate in this planning.