Musculoskeletal Disorders: Introduction

00:01 So we’re going to talk about why do we think about musculoskeletal disorders so much. We know they’re a common problem.

00:08 We know everybody gets some kind of muscle pain, some kind of muscle tension, but it’s more than that. First of all, musculoskeletal disorders are any pain or disability that comes from the bone and joint, and it affects your ability to function. When people feel pain, they don’t work as well, they don’t think as well, they don’t rest as well, and it affects all levels of functioning.

00:32 It’s called the burden of musculoskeletal disease when we look at the dollar amount, the loss of work, and how much damage it does to individuals. We’re going to focus on the big disorders and those where the attention is drawn to it because most of us think, yeah, we get muscle pain when we work out, when we play, and when we do different things, but it’s more than that. We have to worry about the parts of the body that are affected, where we’re going to get these problems, how we’re going to get these problems, and why we deal with it.

01:05 A lot of musculoskeletal disorders are joint deterioration.

01:09 They’re wear and tear in the bones.

01:11 They’re destruction of the bones.

01:13 They’re inappropriate use that causes tearing or non-healing or swelling of the muscles in the body, and cause the bones not to function well.

01:25 So the parts of the body that are affected are the joints, the muscles, and the bones.

01:29 Arthritis is one of the most common.

01:32 You can have rheumatoid arthritis which is autoimmune or you can have osteoarthritis— more wear and tear. We also see a lot of spine disorders that are just the way the body is built.

01:44 It’s not going to function at peak maximal intensity all the time. You’re going to get neck pain. You’re going to get back pain.

01:52 You’re going to have arm pain when you lift too much r lift in the wrong way, when you stress or strain.

01:58 We also know that humans tend to have a lot of differences in their anatomy, a lot of differences in their vertebra, and some of them lead to spinal deformity, spina bifada, or scoliosis, and that becomes a very, very expensive form of musculoskeletal disease.

02:18 With aging, women, particularly, are going to get osteoporosis but both men and women have a hormonal depletion of bone which causes an increased risk of fracture, a decreased ability to function as we want, and causes disability.

02:34 And we always have to think about cancer and issues of the connective tissue.

02:39 So the whole body really is at risk and it is something that we do see. So how do we deal with this? Well we define how much of a problem it is.

02:51 It’s all ages, but we do know that the most expensive problems, the hardest problems to deal with are musculoskeletal problems that start in childhood either with juvenile rheumatoid arthritis or deformities are big ones.

03:05 We also know that working-age adults tend to miss a lot of work from overuse, misuse, or functioning that’s just not appropriate, and then older adults with fractures and other musculoskeletal conditions.

03:20 Just to put some numbers on this, over the age of 18, 126 million Americans have reported musculoskeletal pain that stopped them from being able to function normally.

03:32 We also know that in a year, 1 out of 3 people are affected by back pain or neck pain, and lastly, 18 million people were going to have some chronic issues where they can’t perform their activities of daily living because of musculoskeletal disorders.

03:49 And this leads to people not being able to live independently, needing help, and just it’s a tremendous burden of disease. So musculoskeletal disorders not only stop functioning, but they make people feel bad. They make people unable to do what they want to do, and it affects their other areas of health as well.

04:09 We do know that the burden of the disease is figured in the number of dollars spent on it, the number of days lost to work, and the number of people.

04:17 So if it's 290 million lost work days due to back and neck pain, people think about it and they try to figure out what can they do to make it less? Well, you start by making work more ergonomic with desks that rise and lower, chairs that are more comfortable that have support for your low back, and early detection—knowing when people can continue to work and when they have to stop and stretch.

04:44 We do know that there are refractory periods that after you get full motion you may get 20 to 30 minutes.

04:50 We do know that stretching gives you 2 to 3 hours of increased proprioceptive sense and ease of functioning, after which you’ll lose the benefit.

04:59 Our muscles and bones are not set up to act forever and to act without support. So we’re talking about $213 billion spent every year in direct and indirect costs and $796 billion dollars to treat musculoskeletal disorders.

05:18 That’s why it gets our attention.

05:20 In contrast, the entire GME system is $9 billion so it’s almost 100 times the amount of money spent on musculoskeletal disorders as we spend on training residents to become full fledge physicians. We can predict how much it’s going to be.

05:38 We know where the cost is going to be.

05:40 We know where the breakdown is going to be, but just because we can describe musculoskeletal disorders, doesn’t mean we can successfully treat them. And also, when dealing with humans, it doesn’t mean that humans are going to listen.

05:52 If you tell people that if you crack your joint, don’t crack it again for 20 minutes, some people may listen, most won’t.

06:00 So getting people to listen to their bodies s something that we have to work on more. Getting people to understand what they do, what kind of lifting, how they can lift, and how much they can lift is something that we need to get through to people.

06:15 The other thing is when we don’t understand how the body can heal itself, we take over. Joint replacements cost $66 billion in one year, and that’s the average number, and it’s increasing every year as our population ages. We’re trying other forms of therapy. We’re trying viscosupplementation.

06:36 We’re trying bracing.

06:37 We’re trying other forms of support for the muscles, but people don’t want to wait the 2 to 3 years for a bone to reform, to heal. They want more immediate action even if it means 4 to 6 weeks of physical therapy to get there.

06:52 And whenever you have multiple answers to one question, it mean no one answer is ideal, no one answer is best, and matching the treatment to the person is very important.

07:04 We know that in hospitalized patients, we do tend to take over.

07:06 We do tend to give them physical therapy for large muscles, ccupational therapy for small muscle groups and fine motor movement, and we do try and train them so that they are able to continue to take care of themselves with the goal, of course, being discharge.

07:19 A patient’s goal is not discharge, a patient’s goal is full functioning.

07:23 So some of the costs get figured into the divergent goals that the individuals have and the healthcare system which looks it a floor of how can we get this person home functioning, caring for themselves with minimal discomfort. We do know that we can prevent musculoskeletal disorders with proper use.

07:43 We do know that if somebody goes into, what’s called non-neutral mechanics, and pinches a bone in one spot, two things form bone— Wolff’s Law, the area of greatest pressure causes bone deposition and the piezoelectric forces that come from muscle that stimulate bone formation.

08:01 So by working within those rules and strengthening the areas that need to be strengthened, protecting the core muscle mass that support the body skeleton, is going to be very, very important. But it’s also very hard and it takes continued exercise which we have a tough time getting patients to do.

08:20 So gaining motility and function is our guideline.

08:23 Full motility, full function is our goal, and once we get there, patients will be happier.

08:31 But again, multiple answers to a single question— we don’t have one best answer— we need to keep searching, and research is needed. We need to find the right questions, we need to agree on the questions with our patients— will often have different questions than we have and different goals than we have. As a doc, I can tell you someone came into my office and said, “I did break my leg, but I still plan on running the marathon next week.

08:56 What can you do to help me?” Well, you broke your leg—you shouldn’t, but if they’re going to use crutches that person may still try and run the marathon or hobble the marathon.

09:06 So you need to screen who’s going to get overuse injuries, who’s going to get tears, who’s going to get sprains and strains, and how do we deal with this? And we do know that there’s an unequal distribution of resources, there is a preponderance of the emergency room when the pain gets bad, and less early intervention which would really help prevent permanent damage and help with healing.

09:32 Under 35 years of age, most sprains will heal in 2 weeks.

09:36 Over 35, you add a week a year up until 6 weeks, and after 55 years of age, it takes a lot longer to heal nd there is some evaluation afterwards to make sure that the healing is occurring. We’re also learning about external stimulates for bone growth which may have some place and other ways of addressing a problem that is still trying to be fully understood.

09:59 We’re always asking for more research dollars, more research involvement because the questions are clear. People want to function and they want to function easily and comfortably.

10:09 So getting the government interested, getting funding agencies interested, is a key principle in what we’re dealing with.

10:15 Getting us to understand the questions, the healing time, and where and when we have to intervene is key.

10:23 And how do we get people the proper level of care at the proper time? How do we get them to a doctor when they first start getting microfractures or stress fractures? When do they start getting overuse injuries? When do they start getting laxity of ligaments and start issues? So those are things that we have to address and are working actively to address. We also need to understand that acute pain, subacute, and chronic pain are very different conditions and they have a very different natural history.

10:56 ntervening early and understanding if a disease is going to heal on its own and what the patient needs is observation is very different than a pediatric issue that’s caused by a deformity that is going to worsen over time and some kind of supporting mechanism, supporting structures, ancillary devices may be needed to help it from causing other problems and causing what we call, compensatory problems, because we know if you have a problem in the right upper back eventually it’s going to move to the left lower back as you twist to support it, and then it’s going to hit the pelvis, and it just is a continual decline that gets more expensive, more painful, and more difficult to treat.

11:36 So finding the key points to intervene is critical.

11:41 We also need to coordinate better between physicians, physical therapists, occupational therapists, and a system that helps monitor what’s going on and helps keep people active and healthy.

11:53 At some point, we’ll even get to exercise and lifestyle specialists who are critical to maintaining a healthy lifestyle and a healthy musculoskeletal functioning.

12:02 But again, we’re not there yet, but now that we have a system where knowledge is integrated and we know what’s going on, it’s going to happen more rapidly and we’ll be able to use that to our benefit.