Successful Management of Musculoskeletal Disorders

A National Academy of Sciences study found that musculoskeletal disorders of the back and arm are an important national health problem with over 1,000,000 workers missing time from their job each year, at a cost of over $50 billion a year. When one takes indirect costs such as reduced productivity, loss of customers due to errors made by replacement workers and regulatory compliance into account, estimates place the total yearly cost of all workplace injuries at well over $1 trillion or 10% of United States Gross Domestic Product. Debates regarding causation and subsequent financial responsibility have delayed the opportunity to provide effective prevention in the workplace. Effective prevention of workplace illnesses (musculoskeletal disorders) through active intervention is not only possible, but results in significant costs savings for the employer while reducing the disability experienced by the individual employee.     

Musculoskeletal disorders: primary and secondary interventions.

In the United States alone, the annual cost associated with the diagnosis and care of musculoskeletal trauma amounts to tens of billions of dollars [Occupational Musculoskeletal Disorders: Function, Outcomes and Evidence. Lippincott Williams and Wilkins, Philadelphia]. Moreover, these costs are continuing to increase at an alarming rate. In fact, in the United States today, occupational musculoskeletal disorders are the leading causes of work disability. Changes in health care policy and demand for improved allocation of health care resources by the Federal government have also recently placed greater pressure on health care professionals to provide the most cost-effective treatment for these disorders, as well as to validate treatment effectiveness. Indeed, treatment-outcome monitoring has assumed new importance in medicine. It is particularly essential in musculoskeletal care, which is currently targeted for attention by health care planners because of its high cost and perceived traditional inefficient care. With these facts in mind, the purpose of the present article is to review the status of current primary and secondary interventions for musculoskeletal disorders. Before doing so, a brief discussion of the biopsychosocial model of pain and disability, which is currently the most heuristic approach to intervention, will be provided.     

Work-related low back pain: secondary intervention.

A review of the literature indicates that non-specific low back pain is basically an age-related disorder that is affected by differences in occupation, genetics and personal behavior. The cause of low back pain is unknown in most cases, and most of the treatments in routine use are ineffective. There is no evidence that low back pain has decreased in recent years. Consequently, there are a growing number of investigators who believe that efforts at preventing low back pain are futile; that low back pain is an unavoidable consequence of life that will afflict two thirds of the adult population at some point in their lives. These investigators believe that programs aimed at reducing low back disability are likely to be more effective and less costly. Only a small percentage of people with low back pain become disabled, but this small percentage consumes most of the cost. The literature pertaining to the reduction of low back disability is reviewed and discussed. It is concluded that low back disability can be reduced, and that management (not the health care provider) has the primary responsibility for reducing disability.     

Musculoskeletal complaints among Italian X-ray technology students: a cross-sectional questionnaire survey

Background

There is a high prevalence of musculoskeletal disorders among healthcare professional students. Although recent studies show musculoskeletal disorders are a common problem among X-ray technologists, there are no data on these disorders among students of this healthcare profession. We have therefore estimated the prevalence of musculoskeletal complaints among a group of X-ray technology students.

Methods

The students (n = 109) currently attending the 3-year X-ray technologist school at a large University in the Apulia region of Southern Italy were recruited for the study, with a 100% participation rate. A questionnaire collected data concerning personal characteristics, physical exposure during training activities, and the presence of musculoskeletal symptoms in the neck, shoulders, low back, hand/wrist and legs.

Results

The prevalence of complaints in any body site over the previous 12 months was 37%. Low back pain was the most frequently reported symptom (27%), followed by neck (16%), shoulder (11%), leg (8%) and hand/wrist (5%) pain. Poor physical activity was associated with the complaints.

Conclusions

Our study showed prevalence rates of musculoskeletal complaints among X-ray technology students to be somewhat high, representing about half of those found in Italian technologists. The most common musculoskeletal problem was low back pain, which had also been found in research conducted among nursing students. Our research also showed a significant association between poor physical activity and the presence of musculoskeletal disorders in young university students.

     

The CUPID (Cultural and Psychosocial Influences on Disability) study: methods of data collection and characteristics of study sample

Background

The CUPID (Cultural and Psychosocial Influences on Disability) study was established to explore the hypothesis that common musculoskeletal disorders (MSDs) and associated disability are importantly influenced by culturally determined health beliefs and expectations. This paper describes the methods of data collection and various characteristics of the study sample.

Methods/Principal Findings

A standardised questionnaire covering musculoskeletal symptoms, disability and potential risk factors, was used to collect information from 47 samples of nurses, office workers, and other (mostly manual) workers in 18 countries from six continents. In addition, local investigators provided data on economic aspects of employment for each occupational group. Participation exceeded 80% in 33 of the 47 occupational groups, and after pre-specified exclusions, analysis was based on 12,426 subjects (92 to 1018 per occupational group). As expected, there was high usage of computer keyboards by office workers, while nurses had the highest prevalence of heavy manual lifting in all but one country. There was substantial heterogeneity between occupational groups in economic and psychosocial aspects of work; three- to five-fold variation in awareness of someone outside work with musculoskeletal pain; and more than ten-fold variation in the prevalence of adverse health beliefs about back and arm pain, and in awareness of terms such as “repetitive strain injury” (RSI).

Conclusions/Significance

The large differences in psychosocial risk factors (including knowledge and beliefs about MSDs) between occupational groups should allow the study hypothesis to be addressed effectively.     

Lost working years due to mental disorders: an analysis of the norwegian disability pension registry

Objectives

Mental disorders are prevalent diagnoses in disability benefit statistics, with awards often granted at younger age than for other diagnoses. We aimed to compare the number of lost working years following disability benefit award for mental disorders versus other diagnostic groups.

Methods

Data from the complete Norwegian official registry over disability benefit incidence, including primary diagnoses, were analyzed for the period 2001 to 2003 (N = 77,067), a time-period without any reform in the disability benefit scheme. Lost working years due to disability benefit award before scheduled age retirement at age 67 were calculated.

Results

Musculoskeletal disorders were the commonest reason for disability benefit awards (36.3%) with mental disorders in second place (24.0%). However, mental disorders were responsible for the most working years lost (33.8%) compared with musculoskeletal disorders (29.4%). Individuals awarded disability benefit for a mental disorder were on average 8.9 years younger (46.1 years) than individuals awarded for a musculoskeletal disorder (55.0 years), and 6.9 years younger than individuals awarded for any other somatic disorder (53.0 years). Anxiety and depressive disorders were the largest contributors to lost working years within mental disorders.

Conclusion

Age at award is highly relevant when the total burden of different diagnoses on disability benefits is considered. There is great disparity in total number of lost working years due to disability benefit award for different diagnostic groups. The high number of lost working years from mental disorders has serious consequences for both the individual and for the wider society and economy.     

Adolescent idiopathic scoliosis and back pain

This broad narrative review addresses the relationship between adolescent idiopathic scoliosis (AIS) and back pain. AIS can be responsible for low back pain, particularly major cases. However, a linear relationship between back pain and the magnitude of the deformity cannot be expected for any individual patient. A large number of juvenile patients can remain pain-free. The long-term prognosis is rather benign for many cases and thus a tailored approach to the individual patient seems mandatory. The level of evidence available does not allow stringent recommendations for any of the disorders included in this review.     

Chronic Ingestion of Advanced Glycation End Products Induces Degenerative Spinal Changes and Hypertrophy in Aging Pre-Diabetic Mice

Intervertebral disc (IVD) degeneration and pathological spinal changes are major causes of back pain, which is the top cause of global disability. Obese and diabetic individuals are at increased risk for back pain and musculoskeletal complications. Modern diets contain high levels of advanced glycation end products (AGEs), cyto-toxic components which are known contributors to obesity, diabetes and accelerated aging pathologies. There is little information about potential effects of AGE rich diet on spinal pathology, which may be a contributing cause for back pain which is common in obese and diabetic individuals. This study investigated the role of specific AGE precursors (e.g. methylglyoxal-derivatives (MG)) on IVD and vertebral pathologies in aging C57BL6 mice that were fed isocaloric diets with standard (dMG+) or reduced amounts of MG derivatives (dMG-; containing 60-70% less dMG). dMG+ mice exhibited a pre-diabetic phenotype, as they were insulin resistant but not hyperglycemic. Vertebrae of dMG+ mice displayed increased cortical-thickness and cortical-area, greater MG-AGE accumulation and ectopic calcification in vertebral endplates. IVD morphology of dMG+ mice exhibited ectopic calcification, hypertrophic differentiation and glycosaminoglycan loss relative to dMG- mice. Overall, chronic exposure to dietary AGEs promoted age-accelerated IVD degeneration and vertebral alterations involving ectopic calcification which occurred in parallel with insulin resistance, and which were prevented with dMG- diet. This study described a new mouse model for diet-induced spinal degeneration, and results were in support of the hypothesis that chronic AGE ingestion could be a factor contributing to a pre-diabetic state, ectopic calcifications in spinal tissues, and musculoskeletal complications that are more generally known to occur with chronic diabetic conditions.     

The relationship of corticospinal excitability with pain,motor performance and disability in subjects with chronic wrist/hand pain

There is a growing body of evidence of changes in corticospinal excitability associated with musculoskeletal disorders, however there is a lack of knowledge of how these changes relate to measures of pain, motor performance and disability. An exploratory study was performed utilizing Transcranial Magnetic Stimulation to investigate differences in corticospinal excitability in the Abductor Pollicis Brevis (APB) between 15 pain-free subjects and 15 subjects with chronic wrist/hand pain and to determine how corticospinal excitability was associated with measures of pain (visual analog scale, AUSCAN™), hand motor performance (isometric and key pinch strength, Purdue Pegboard Test), disability (AUSCAN™), and spinal motoneuronal excitability. Input–output curves demonstrated increased corticospinal excitability of the APB in the affected hand of subjects with chronic pain (p < 0.01). Changes in corticospinal excitability were significantly correlated with pain intensity (r = 0.77), disability (r = 0.58), and negatively correlated with motoneuronal excitability (r = −0.57). Corticospinal excitability in subjects with heterogeneous injuries of the wrist/hand was associated with disability and pain.     

Physical inactivity is associated with narrower lumbar intervertebral discs,high fat content of paraspinal muscles and low back pain and disability

IntroductionAlthough physical inactivity has been associated with numerous chronic musculoskeletal complaints, few studies have examined its associations with spinal structures. Moreover, previously reported associations between physical activity and low back pain are conflicting. This study examined the associations between physical inactivity and intervertebral disc height, paraspinal fat content and low back pain and disability.MethodsSeventy-two community-based volunteers not selected for low back pain underwent magnetic resonance imaging (MRI) of their lumbosacral spine (L1 to S1) between 2011 and 2012. Physical activity was assessed between 2005 and 2008 by questionnaire, while low back pain and disability were assessed by the Chronic Pain Grade Scale at the time of MRI. Intervertebral disc height and cross-sectional area and fat content of multifidus and erector spinae were assessed from MRI.ResultsLower physical activity levels were associated with a more narrow average intervertebral disc height (β −0.63 mm, 95% confidence interval (CI) −1.17 mm to −0.08 mm, P = 0.026) after adjusting for age, gender and body mass index (BMI). There were no significant associations between physical activity levels and the cross-sectional area of multifidus or erector spinae. Lower levels of physical activity were associated with an increased risk of high fat content in multifidus (odds ratio (OR) 2.7, 95% CI 1.1 to 6.7, P = 0.04) and high-intensity pain/disability (OR = 5.0, 95% CI 1.5 to 16.4, P = 0.008) after adjustment for age, gender and BMI.ConclusionsPhysical inactivity is associated with narrower intervertebral discs, high fat content of the multifidus and high-intensity low back pain and disability in a dose-dependent manner among community-based adults. Longitudinal studies will help to determine the cause and effect nature of these associations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0629-y) contains supplementary material, which is available to authorized users.     

Risk Factors and Disability Associated with Low Back Pain in Older Adults in Low- and Middle-Income Countries. Results from the WHO Study on Global AGEing and Adult Health (SAGE)

Background

Back pain is a common disabling chronic condition that burdens individuals, families and societies. Epidemiological evidence, mainly from high-income countries, shows positive association between back pain prevalence and older age. There is an urgent need for accurate epidemiological data on back pain in adult populations in low- and middle-income countries (LMICs) where populations are ageing rapidly. The objectives of this study are to: measure the prevalence of back pain; identify risk factors and determinants associated with back pain, and describe association between back pain and disability in adults aged 50 years and older, in six LMICs from different regions of the world. The findings provide insights into country-level differences in self-reported back pain and disability in a group of socially, culturally, economically and geographically diverse LMICs.

Methods

Standardized national survey data collected from adults (50 years and older) participating in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) were analysed. The weighted sample (n = 30, 146) comprised respondents in China, Ghana, India, Mexico, South Africa and the Russian Federation. Multivariable regressions describe factors associated with back pain prevalence and intensity, and back pain as a determinant of disability.

Results

Prevalence was highest in the Russian Federation (56%) and lowest in China (22%). In the pooled multi-country analyses, female sex, lower education, lower wealth and multiple chronic morbidities were significant in association with past-month back pain (p<0.01). About 8% of respondents reported that they experienced intense back pain in the previous month.

Conclusions

Evidence on back pain and its impact on disability is needed in developing countries so that governments can invest in cost-effective education and rehabilitation to reduce the growing social and economic burden imposed by this disabling condition.     

Increased Insomnia Symptoms Predict the Onset of Back Pain among Employed Adults

Background

Back pain is among the most prevalent pain disorders causing chronic disability among adults, and insomnia is a common co-morbidity. However, whether insomnia precedes back pain or vice versa remains unclear. The current study tested the temporal association between insomnia and back pain.

Methods

A longitudinal design was used to investigate whether changes in insomnia over time predict the onset of back pain and vice versa. The study was conducted on a cohort of active healthy working adults (N = 2,131, 34% women) at three time points (T1, T2, and T3) over a period of 3.7 years (range = 2.2–5.12) years. Logistic regression analysis was used to test whether increased insomnia symptoms from T1 to T2 predicted the onset of new back pain. Ordinary least squares regression was used to test whether the existence of back pain at T2 predicted an increase in insomnia from T2 to T3.

Results

The results indicated that after controlling for socioeconomic variables, self-reported health, lifestyle behaviors, and anthropometrics, a T1–T2 increase in insomnia symptoms was associated with a 1.40-fold increased risk of back pain at T3 (OR = 1.40; 95% CI = 1.10–1.71). No support was found for reverse causation; i.e., that back pain predicts subsequent increase in insomnia.

Conclusions

Insomnia appears to be a risk factor in the development of back pain in healthy individuals. However, no evidence of reverse causation was found.     

Prognosis in Acute Occupational Low Back Pain: Methodologic and Practical Considerations

Work-related or occupational low back pain (OLBP) is the leading cause of disability due to work-related conditions. The clinical course of this disorder is highly variable. Accurate prediction of disability outcomes in acute OLBP can lead to better selection of those likely to benefit from intensive interventions, identification of specific issues for intervention, and more efficient patient selection in clinical trials. The basis for disability prognostication has been developed through studies of outcomes in acute OLBP. These include investigations based on administrative data, workplace studies, and clinical studies in physicians' offices or workplaces. Each study design has inherent strengths and limitations that affect the accuracy of the resulting predictive models. Practical concerns for use of prognostic models in clinical settings include generalizability of results, feasibility of data collection and interpretation, acceptability to patients, cost, and linking prognosis to effective interventions. Ethical concerns include informed consent, confidentiality issues and inappropriate negative labeling. An informed choice of prognostic model and associated measures based on specific goals is needed to develop an appropriate application for a particular clinical or research situation. Future research may lead to greater use of these models, improving outcomes for workers with OLBP.     

Can the use of physical modalities for pain control be rationalized by the research evidence?

Physical modalities, including cold and heat, are widely used in the conservative management of pain associated with musculoskeletal disorders. This review has critically appraised the literature supporting the use of these modalities in the treatment of musculoskeletal pain. It was concluded that, apart from a few exceptions and in a few types of disorders, existing evidence does not support the use of these modalities in long-term pain control. There was, however, evidence that several modalities, specifically cold and a form of deep heat (shortwave diathermy), do have short-lived analgesic effects and so may contribute to more painfree function in the short term. Further research is clearly warranted to define the short- and long-term therapeutic efficacy of physical modalities in the treatment of musculoskeletal pain to justify their continued use in clinical practice.     

Mechanisms of central sensitization, neuroimmunology & injury biomechanics in persistent pain: implications for musculoskeletal disorders.

This review will offer an overview of the mechanistic pathways of chronic pain associated with musculoskeletal disorders (MSDs). Traditional electrophysiological pain pathways of these injuries will be reviewed. In addition, recent research efforts in persistent pain have characterized a cascade of neuroimmunologic events in the central nervous system that manifests in pain behaviors and neurochemical nociceptive responses. Physiologic changes in the central nervous system will be covered as they pertain to the interplay of these two areas, and also as they focus on MSDs and injuries. One such injury leading to persistent pain is radiculopathy, which results from nerve root compression or impingement and leads to low back pain. This painful syndrome will be used as an example to provide a context for presenting immune mechanisms of chronic pain and their relationship to injury. Measures of injury biomechanics are presented in the context of the resulting pain responses, including behavioral sensitivity, local structural changes, and cellular and molecular changes in the CNS. Lastly, based on these findings and others, a discussion is provided highlighting areas of future work to help elucidate methods of injury diagnosis and development of therapeutic treatments.     

Contribution of chronic disease to the burden of disability

Background

Population ageing is expected to lead to strong increases in the number of persons with one or more disabilities, which may result in substantial declines in the quality of life. To reduce the burden of disability and to prevent concomitant declines in the quality of life, one of the first steps is to establish which diseases contribute most to the burden. Therefore, this paper aims to determine the contribution of specific diseases to the prevalence of disability and to years lived with disability, and to assess whether large contributions are due to a high disease prevalence or a high disabling impact.

Methodology/Principal Findings

Data from the Dutch POLS-survey (Permanent Onderzoek Leefsituatie, 2001–2007) were analyzed. Using additive regression and accounting for co-morbidity, the disabling impact of selected chronic diseases was calculated, and the prevalence and years lived with ADL and mobility disabilities were partitioned into contributions of specific disease. Musculoskeletal and cardiovascular disease contributed most to the burden of disability, but chronic non-specific lung disease (males) and diabetes (females) also contributed much. Within the musculoskeletal and cardiovascular disease groups, back pain, peripheral vascular disease and stroke contributed particularly by their high disabling impact. Arthritis and heart disease were less disabling but contributed substantially because of their high prevalence. The disabling impact of diseases was particularly high among persons older than 80.

Conclusions/Significance

To reduce the burden of disability, the extent diseases such as back pain, peripheral vascular disease and stroke lead to disability should be reduced, particularly among the oldest old. But also moderately disabling diseases with a high prevalence, such as arthritis and heart disease, should be targeted.     

The use of H2 antagonists in treating and preventing NSAID-induced mucosal damage

Pain affects the quality of life for millions of individuals and is a major reason for healthcare utilization. As populations age, medical personnel will need to manage more and more patients suffering from pain associated with degenerative and inflammatory musculoskeletal disorders. Nonsteroidal anti-inflammatory drugs (NSAIDs) are an effective treatment for both acute and chronic musculoskeletal pain; however, their use is associated with potentially significant gastrointestinal (GI) toxicity. Guidelines suggest various strategies to prevent problems in those at risk for NSAID-associated GI complications. In this article, we review the data supporting one such strategy - the use of histamine type-2 receptor antagonists (H2RAs) - for the prevention of GI adverse events in NSAID users. Older studies suggest that high-dose H2RAs are effective in preventing upper GI ulcers and dyspepsia. This suggestion was recently confirmed during clinical trials with a new ibuprofen/famotidine combination that reduced the risk of ulcers by 50% compared with ibuprofen alone.     

Musculoskeletal discomfort and feeling of fatigue among female professional workers: the need for ergonomics consideration.

Subjective feeling of general fatigue and physiological strain were studied in one hundred female professional employees of industrial worker and full-time nurses. Using an interview questionnaire the feeling of fatigue were studied. The subjects were asked to indicate on the body diagram all the areas of musculoskeletal pain from which they perceived discomfort. Furthermore physical strength test consisting of grip test, back and leg strength test were carried out before and after work on all subjects. The results indicated that the two groups of employees showed different symptoms of "pain" and/or "fatigue," with regard to the different parts of body. It was also noted that the physical strength after work was lower for both groups as compared to before work and even lower for the industrial workers than the nurses. The feeling of fatigue between the two investigated groups was not significantly different, but for the musculoskeletal pain was highly significantly different. The worker group used also more pain-killing drugs for releasing the muscle pain. It was evident that ergonomics intervention for female professional workers was of great importance and urgency, particularly for making the workplace more human. Improvement of the working conditions, better organization of work, and ergonomics interventions are suggested as necessary measures for reduction of pain and feeling of discomfort.     

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.

OBJECTIVE--To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes. DESIGN--Inception cohort study. SETTING--Primary care. PATIENTS--103 patients with acute localised non-specific back pain lasting less than 72 hours. MAIN OUTCOME MEASURES--Complete recovery (disappearance of both pain and disability) and return to work. RESULTS--90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender. CONCLUSIONS--The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.