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New Approaches to Musculoskeletal Wellness

New Approaches to Musculoskeletal Wellness. Steve Overman, MD MPH September 20, 2003. Musculoskeletal (MS) Illness Impacts for past Decade? - Near Economic Recession. The Costs of MS Conditions (as a % of US Gross Domestic Product) DIRECT INDIRECT TOTAL 1963 0.3 0.3 0.7

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New Approaches to Musculoskeletal Wellness

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  1. New Approaches to Musculoskeletal Wellness Steve Overman, MD MPH September 20, 2003

  2. Musculoskeletal (MS) Illness Impacts for past Decade? - Near Economic Recession The Costs of MS Conditions (as a % of US Gross Domestic Product) DIRECT INDIRECT TOTAL 1963 0.3 0.3 0.7 1988 1.2 1.3 2.5 1997 2.9 1.2 4.1 Yelin, International Journal of Advances in Rheumatology 2003: 1; 20-23

  3. Demographic Shift Population is aging Expected doubling in number of people older than 65 between 1990 and 2020

  4. Prevalence of Osteoarthritis of the Hip with Age

  5. Osteoporosis • Fragility fractures have doubled in the last decade • 40% of all women over 50 years will suffer an osteoporotic fracture

  6. Back Pain • Low back pain is the most frequent cause of limitation of activity in the young and middle aged • One of the most common reasons for medical consultation • The most frequent occupational injury • The second leading cause of sick leave

  7. Rheumatoid Arthritis Lifetime costs of RA rival those of CAD or Stroke

  8. The Bone and Joint Decade • 2000-2010 For Prevention and Treatment of Musculo-skeletal Disorders

  9. Musculo-skeletal disorders are the most common causes of severe long-term pain and physical disability affecting many millions of people across the globe. They have an enormous impact on the individual, society and health care social systems With the increasing number of older people and changes in lifestyle occuring throughout the world, this trend will increase dramatically over the next decade and beyond November 1999

  10. Today’s Goals • To help you understand reasons why MS Illness Impacts are rising despite our advancing scientific knowledge and high-tech health care system • To describe shifts in medical paradigms that are changing our approaches to MS Care • Review new approaches to care that promote Musculoskeletal Wellness

  11. How might we help a patient achieve MSWellness? • Correct deformities or control inflammation from injury or disease? • Enhance function to meet a patient’s expectations? • Control or eliminate pain? • Help a person enjoy and find meaning in life despite pain or disability?

  12. 20th Century Medical Paradigms:MS costs and disability have increased • Biology - Biologic research for understanding disease and illness. • Clinical Care – Mono-therapies for problems based simple cause & effect concepts of disease pathogenesis. • Health Care System – Centralized organization around provider priorities for the treatment of acute care problems

  13. What is a Medical Paradigm? • A “paradigm” is an overarching concept of reality. A set of assumptions, concepts, values, and practices that constitutes a way of viewing reality for the community that shares them, and can be thought of as the framework that has unwritten rules but directs actions. • “Medical paradigms” are the unwritten rules that direct the actions of scientific investigation, clinical analysis and treatment, and health care system development.

  14. When do we need New Paradigms? “When we are unable to solve present problems within a given paradigm, our view of reality must change, as must the way we perceive, think, and value the world. We must take on new assumptions and expectations that will transform our theories, traditions, rules, and standards of practice. We must create a new paradigm in which we are able to solve the insolvable problems of the old paradigm.”

  15. New Medical Paradigms for Enhancing Wellness • Biology of Illness paradigm Bio-Psycho-Social Illness • Clinical Care paradigm Multi-dimensional care plans • Health Care System paradigm Patient-Centered organization & care delivery

  16. How do Paradigms Shift? When one paradigm loses influence and another takes over, there is a paradigm shift. New paradigms take hold suddenly. The sudden change occurs when the keepers of the old paradigm die, and the new paradigms then leap into prominence based on long-before proven concepts.

  17. “It is more important to know what sort of patient has a disease, than what sort of disease a patient has.” Sir William Osler

  18. New Paradigms for 21st Century:real world examples • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Phase of chronic illness • Rational poly-pharmacy • Patient-centered Care Organization and Delivery • Chronic Illness Care Systems • Self-administered QOL and Function Questionnaires

  19. New Paradigms for 21st Century Musculoskeletal Care • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Rational poly-pharmacy • Phase of chronic illness • Patient-centered Care Organization and Delivery • Self-administered QOL and Function Questionnaires • Chronic Illness Care Systems

  20. US Government Programs • Development of Occupational Illness and Injury Contingency Management Systems, 1987 • Attributes of Model PNI Based Interventions for HIV Sero-positive Members of Military and Non-Military Occupational Health Service Delivery Programs of the United States Public Health Service, 1992

  21. New Paradigms for 21st Century Musculoskeletal Care • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Rational poly-pharmacy • Phase of chronic illness • Patient-centered Care Organization and Delivery • Self-administered QOL and Function Questionnaires • Chronic Illness Care Systems

  22. Bio-Psycho-Social Illness Dean Ornish, MD, comments on the positive outcomes of a controlled study of group support in cancer patients. “Imagine that patients took drug X for only six weeks, yet 5 to 6 years later it prolonged survival in malignant melanoma. Full-page ads would proclaim the benefits in the medical journals and news magazines.” p.57 in Love and Survival

  23. New Paradigms for 21st Century Musculoskeletal Care • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Phase of chronic illness • Rational poly-pharmacy • Patient-centered Care Organization and Delivery • Self-administered QOL and Function Questionnaires • Chronic Illness Care Systems

  24. Chronic Illness Phases Pat FennellJoy Selak Crisis  Getting sick Stabilization  Living sick Grief  Death of self Integration  Living well

  25. New Paradigms for 21st Century Musculoskeletal Care • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Phase of chronic illness • Rational poly-pharmacy • Patient-centered Care Organization and Delivery • Self-administered QOL and Function Questionnaires • Chronic Illness Care Systems

  26. Triple Therapy in RA p= 0.05 p= 0.002 MTX + HCQ (n = 58) MTX + HCQ + SSZ (n = 58) MTX + SSZ (n = 55) 78 p = 0.005 60 55 % of Patients 49 40 29 26 18 16 ACR20 ACR50 ACR70 Adapted from O’Dell JR et al. Arthritis Rheum. 2002;46:1164-1170.

  27. New Paradigms for 21st Century Musculoskeletal Care • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Rational poly-pharmacy • Phase of chronic illness • Patient-centered Care Organization & Delivery • Chronic Illness Care Systems • Self-administered QOL and Function Questionnaires

  28. Chronic Care Model • The Community • The Health System • Self-management Support • Delivery System Design • Decision Support • Clinical Information Systems http://www.improvingchroniccare.org

  29. New Paradigms for 21st Century Musculoskeletal Care • Bio-Psycho-Social Illness • PNI (psycho-neuro-immunology) research • Love and Survival, by Dean Ornish, MD • Multi-Dimensional Care Plans • Rational poly-pharmacy • Phase of chronic illness • Patient-centered Care Organization & Delivery • Chronic Illness Care Systems • Self-administered QOL and Function Questionnaires

  30. Health Assessment Questionnaire (HAQ) • Widely accepted, validated, rheumatology-specific instrument to assess physical function in RA (self-administered) • Gold standard of OMERACT/FDA • 20 questions covering 8 activities • Dressing and grooming, arising, eating, walking, hygiene, reaching, gripping, activities of daily living • HAQ Disability Index (HAQ DI) • Scores the worst items within each of the 8 domains • Based on use of aids and devices Buchbinder R et al. Arthritis Rheum. 1995;38:1568-1580. Sullivan FM et al. Ann Rheum Dis. 1987;46:598-600.

  31. Clinical Importance of HAQ Scores • The HAQ has proven to be more predictive of RA disease progression than any other measure of the ACR response criteria • HAQ scores predict • Functional status • Work disability • Cost of treatment • Joint replacement surgery • Death

  32. Disability and Annual Costs:*Pre-Biologics Era * Hospitalization, surgery, loss of employment, long-term care Fries JF. Ann Rheum Dis. 1999;58(suppl 1):I86-I89.

  33. Healing Practices for Musculoskeletal Wellness CARING CLINCAL • Prevention • Early Detection and Treatment • Multi-dimensional, phase of Illness care plan COACHING • Self-management Teaching • Assisting the Illness to Wellness Journey

  34. Healing Practices for Musculoskeletal Wellness CARING CLINCAL • Prevention • Early Detection and Treatment • Multi-dimensional, phase of Illness care plan COACHING • Self-management Teaching • Assisting the Illness to Wellness Journey

  35. Prevention Osteoporosis • a silent disease ………. unless • fractures occur Then, pain and disability maybe irreversible.

  36. NORA Study of Disease Burden • 200,000 postmenopausal women without DXA for > 1 year • 6% osteoporosis => 27% of fractures @ 1 yr. (~ 10 fractures / 100 patient-years) • 40% osteopenic => 52% of fractures @ 1 yr. (~ 4 fractures / 100 patient-years)

  37. Risk Factors for Hip Fracture Skeletal RiskFactors for Fx Non-Skeletal Risk Factors for Falls/Fx -Age (>80 yr) -Poor balance/gait -Impaired eyesight -Meds that increase risk of falling -Loss of soft tissue hip padding -History of falls -Fall-related injury Fx Risk -Low BMD (T< 2.5) -Previous Fx -Family history Fx -Smoking

  38. Risk Reduction in Non-Vertebral Fracture at 18 Monthswith Calcium and Vitamin D Supplementation 32% p = 0.015 43% p = 0.043 Subjects Treated and Followed for 18 Months Chapuy, et. al., NEJM 1992; 327:1637-1642.

  39. Osteoporosis Fracture Prevention • Prevention of bone loss • Calcium & vitamin D • Reduce alcohol & smoking • Use hormones or equivalents • Identify rapid losers and treat with anti-resorptives • Fracture prevention • Strength exercises for back and squatting • Balance through Tai Chi • Maintain activity & reduce fear

  40. Healing Practices for Musculoskeletal Wellness CARING CLINCAL • Prevention • Early Detection and Treatment • Multi-dimensional, phase of Illness care plan COACHING • Self-management Teaching • Assisting the Illness to Wellness Journey

  41. Early Detection and Treatment The Urgent Care of Rheumatoid Arthritis

  42. Joint Erosions Occur Early in RA • Up to 93% of patients with<2 years of RA may have radiographic abnormalities • Erosions can bedetected by MRI within 4 months of RA onset • Rate of progression is significantly more rapid in the first year than in the second and third years Maximum % Joints Affected Hand MTP All Year Fuchs HA et al. J Rheumatol. 1989;16:585-591. McQueen FM et al. Ann Rheum Dis. 1998;57:350-356. van der Heijde DM et al. J Rheumatol. 1995;22:1792-1796.

  43. Stages of RA Early Intermediate Late Courtesy of J. Cush, 2002.

  44. ACR Criteria for Classification of RA(1-4 of 6 weeks duration) • Morning stiffness • Arthritis of 3 or more joint areas • Arthritis of hand joints • Symmetric arthritis • Rheumatoid nodules • Serum rheumatoid factor • Radiographic changes Arnett FC, et al. Arthritis Rheum. 1988;31:315-324.

  45. Median Lag Time to RA Diagnosis Total Lag Time = time between symptom onset and 1st definite diagnosis Medical Encounter Lag Time = time between symptom onset and 1st medical encounter Diagnosis Lag Time = time between 1st medical encounter and 1st definite diagnosis Weeks Total Lag Time * Medical Encounter Lag Time Diagnosis Lag Time * 1st diagnosis by internist (n=10), by rheumatologist (n=71) Chan KA et al. Arthritis Rheum. 1994;37:814-820.

  46. Rapid referral to a rheumatologist advised with clinical suspicion of RA, which may be supported by the presence of any of the following: Early Referral Algorithm forNewly Diagnosed RA • 3 swollen joints • MTP/MCP involvement • Positive squeeze test • Morning stiffness 30 minutes Emery P et al. Ann Rheum.Dis. 2002:61:290-297.

  47. Magnetic Resonance Imaging as Diagnostic Tool Erosions Detected: X-rays vs MRI (%) X-ray MRI McQueen FM et al. Ann Rheum Dis. 1999;58:156-163. McQueen FM et al. Ann Rheum Dis. 1998;57:350-356.

  48. Steroids in Early Rheumatoid Arthritis • 128 patients with <2 years of disease • 2 years of blinded treatment, then blinded taper • During blinded taper, rate of erosions = placebo rate 8 7 6 5 4 3 2 1 0 Larsen Score* Prednisone Placebo Prednisone 0 1 2 3 Year * Mean (95% CI) after log transformation for patients with radiographs at all time points. Hickling P et al. Br J Rheum. 1998;37:930-936.

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