New Approaches to Musculoskeletal Wellness

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
Todays 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 MS Wellness?

• Correct deformities or control inflammation from
  injury or disease?
• Enhance function to meet a patients
  expectations?
• Control or eliminate pain?
• Help a person enjoy and find meaning in life
  despite pain or disability?

12
20th Century Medical ParadigmsMS 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

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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 Fennell Joy 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 ODell JR et al. Arthritis Rheum.
2002461164-1170.
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.
1995381568-1580. Sullivan FM et al. Ann Rheum
Dis. 198746598-600.
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 CostsPre-Biologics Era
Hospitalization, surgery, loss of employment,
long-term care
Fries JF. Ann Rheum Dis. 199958(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.

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NORA Study of Disease Burden

• 200,000 postmenopausal women without DXA for gt 1
  year
• 6 osteoporosis gt 27 of fractures _at_ 1 yr. (
  10 fractures / 100 patient-years)
• 40 osteopenic gt 52 of fractures _at_ 1 yr. (
  4 fractures / 100 patient-years)

38
Risk Factors for Hip Fracture
Skeletal RiskFactors for Fx
Non-Skeletal Risk Factors for Falls/Fx
-Age (gt80 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 (Tlt 2.5) -Previous Fx -Family history
Fx -Smoking
39
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 3271637-1642.
40
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

41
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

42
Early Detection and Treatment

• The Urgent Care
• of
• Rheumatoid Arthritis

43
Joint Erosions Occur Early in RA

• Up to 93 of patients withlt2 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. 198916585-591. McQu
een FM et al. Ann Rheum Dis. 199857350-356. van
der Heijde DM et al. J Rheumatol.
1995221792-1796.
44
Stages of RA
Early
Intermediate
Late
Courtesy of J. Cush, 2002.
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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.
198831315-324.
47
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 (n10), by
rheumatologist (n71)
Chan KA et al. Arthritis Rheum. 199437814-820.
48
Early Referral Algorithm forNewly Diagnosed RA

• Rapid referral to a rheumatologist advised with
  clinical suspicion of RA, which may be supported
  by the presence of any of the following

• ?3 swollen joints
• MTP/MCP involvement
• Positive squeeze test
• Morning stiffness ?30 minutes

Emery P et al. Ann Rheum. Dis. 200261290-297.
49
Magnetic Resonance Imaging as Diagnostic Tool
Erosions Detected X-rays vs MRI ()
X-ray
MRI
McQueen FM et al. Ann Rheum Dis.
199958156-163. McQueen FM et al. Ann Rheum Dis.
199857350-356.
50
Steroids in Early Rheumatoid Arthritis

• 128 patients with lt2 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. 199837930-936.
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DMARD Treatment The Earlier the Better

Delayed treatment (median treatment lag time, 123
days n 109)
Early treatment (median treatment lag time, 15
days n 97)
DMARDs chloroquine or salazopyrine
Median Sharp Score

p lt 0.05 vs delayed-treatment group. Lard LR et
al. Am J Med. 2001111446-451.
52
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

53
Fibromyalgia Multi-dimensional
CareVegetable Soup Treatment

• Where I focus evaluation treatment?
• Pain
• Sleep
• Inflammation
• Fatigue
• What the patient must do to help?
• Learn
• Let go - breathe
• Exercise
• Sleep

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Fibromyalgia Phase of Illness CareThe Stuck
Car

• I - Triggers
• Neck trauma, inflammation, stress
• II - Perpetuators
• Poor sleep, frustration, reduced exercise
• III Irreversible Changes
• Chemical and gene changes of the
  neuro-endo-immune systems

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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

56
Back Pain Self-management

• Prevention Flat back bending, not smoking,
  exercise
• Early Detection It is not a back strain!!!!
• Treatment Immobilize, anti-inflammatory, change
  movement exercise activities
• Prevent Re-injury Toilet squatting exercise
• Awareness of Illness Cycles Flares and
  remissions based on regular ADLs

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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

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Long-term Outcomes in OA
Reduced QOL and life expectancy
Cartilage destruction
Functional disability
Work disability
Treatment side effects
Psychosocial dysfunction
Comorbidity
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Knee OsteoarthritisPrevention, Treatment
Self-care

• Exercise movement program
• Nutritional supplements glucosamine, vitamins D
  and C
• Orthoses braces
• Analgesics
• Anti-inflammatory meds
• Corticosteroid injections
• Hyaluronic acid injections

63
The Phases Of Illness Impacts

• Crisis
• Stabilization
• Grief
• Integration

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Summary

• Early Detection
• Screening clinics
• Urgent care visits
• Multi-dimensional, Phase of Illness Care
• Diet - Omega Diet
• Exercise - Cross Training gt stretching,
  strengthening, conditioning, balance,
  relaxation-breathing
• Mind Spirit counseling, reading, reflecting,
  giving
• Medications immune system, sleep, pain
• Hands on care - massage, acupuncture

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Summary

• Patient-Centered Care Management
• Self-report monitoring function, symptoms,
  pain, confidence, goals
• Teaching visits - nurse visit program
• Patient groups - Coaching, patient support
• Illness to Wellness
• Counselor / coach - in office
• Patient journey visits no meds or labs

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• If you dont know where you are going, you will
  wind up somewhere else.
• Yogi Berra