https://doi.org/10.5812/aapm.85532

Musculoskeletal Disorders a Universal Source of Pain and Disability Misunderstood and Mismanaged: A Critical Analysis Based on the U.S. Model of Care

authors:

avatar Khalid M Malik ORCID 1 , * , avatar Rena Beckerly 1 , avatar Farnad Imani ORCID 2

University of Illinois, Chicago, United States
Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
Anesthesiology and Pain Medicine: Vol.8, issue 6; e85532
published online: December 15, 2018
article type: Review Article
received: October 19, 2018
revised: November 13, 2018
accepted: November 22, 2018

How To Cite Malik K M, Beckerly R, Imani F. Musculoskeletal Disorders a Universal Source of Pain and Disability Misunderstood and Mismanaged: A Critical Analysis Based on the U.S. Model of Care. Anesth Pain Med. 2018;8(6):e85532. https://doi.org/10.5812/aapm.85532.

Abstract

Musculoskeletal disorders are the leading source of pain and disability globally but are especially prevalent in the industrialized nations including the U.S. In addition to the substantial individual suffering caused the rising monetary costs of these disorders are noteworthy. In the U.S. alone the annual costs have been estimated to be $874 billion 5.7% of the annual U.S. G.D.P. Despite these expenditures the care provided to patients with musculoskeletal disorders is highly variable and has regularly been shown to have suboptimal outcomes. The many reasons for this ineffective care include the mutable nature of the prevailing syndromes and their limited and variable understanding. The care rendered by a broad and incongruent group of providers who practice disparate methodologies and employ variable treatments. Disorderedly triage comprised of arbitrary selection of providers, care methodologies, and treatments, which is prone to a range of extraneous influences. Treatments that are unable to apprehend the causative pathological processes, which are therefore progressive, cause irreversible damage to the respective musculoskeletal structures, and result in enduring pain and disability. The overall lack of preventative care and the consequent prevalence of these disorders especially in specific work environments and with certain high-risk life styles. This article makes recommendations for better understanding, prevention, early recognition, timely employment of disease altering therapies, streamlining the existing care, and policy initiatives for waste confinement and improvement. These discernments may improve the overall quality of care provided to these patients, diminish the staggering pain and disability caused, and can reduce the immense costs incurred.

1. Context

The back and neck disorders, arthritic conditions, and soft tissue syndromes involving the tendons, ligaments, muscles, and cartilages make-up the bulk of musculoskeletal disorders (MSKDs). These conditions are a dominant source of pain and disability globally, but are especially prevalent in the industrialized nations including the U.S. (1). In addition to the substantial individual suffering, the monetary costs of these disorders, to the individuals and the society as a whole, are astounding (2). In the U.S. alone the rising yearly costs of MSKDs have been estimated to be $874 billion 5.7% of the annual U.S. G.D.P. (3). Despite these mounting costs the care provided to patients with MSKDs in the U.S. has regularly been shown to have suboptimal outcomes (4-6). In addition, the costs incurred exhibit marked regional variability signifying distinct subjectivity in the use of the available resources (5). This article highlights the prevalence, costs and disability from MSKDs in the U.S., explores the many reasons for and consequences of this ineffective care, and proposes strategies for improvement.

2. Prevalence, Disability and Costs of MSKDs

2.1. Prevalence

MSKDs are common worldwide but are prevalent in the industrialized nations including the U.S. (Table 1) (1, 3). The National Health Interview (NHI) Survey conducted by the U.S. census bureau in 2012 reported over half (126.6 million, 54%) of the adults suffering from MSKDs a far greater frequency than circulatory (31%) or chronic respiratory conditions (28%) (1). Low back, neck and chronic joint pains were the most prevalent MSKDs with low back pain reported by 66 million and chronic joint pains by 63.1 million adult Americans (1). The prevalence of MSKDs increased with age and chronic joint pains were reported by 40% of the Americans over the age of 65 years (1). Similarly, from 2010 to 2011, of the 1.3 billion medical diagnoses made in the U.S., 223.6 million (18%) pertained to MSKDs (7, 8). The most common diagnoses rendered were “other and unspecified disorders of the back” and “other and unspecified disorders of joints” given in 12.7 % and 8.6% persons, respectively (7, 8).

Table 1.

Prevalence, Disability and Costs of Musculoskeletal Disorders in U.S.

MSKD
Prevalence
MSKDs are common worldwide but are prevalent in industrialized nations particularly in U.S.
Source (1)
MSKDs were reported by 54% of adults in the U.S. 126.6 million individuals over the age of 18 years
MSKDs reported with much greater frequency than other common health related conditions. Circulatory disorders reported by 31%; chronic respiratory conditions by 28% of the adult Americans
Low back, neck and chronic joint pains were the most common MSKDs reported; low back pain reported by 66 million (28%) adults, chronic joint pains by 63.1 million (27%) adults
MSKDs reported with increasing frequency in older individuals, their prevalence highest in ages between 45 and 64 years. Prevalence of chronic joint pain and arthritis increased to 40% in individuals 65 years and older
Sources (7, 8)
Of the 1.3 billion medical diagnoses made 223.6 million (18%) pertained to MSKDs
Of the 4,128 diagnoses/1000 population, 723 (17.5%) concerned MSKDs
The most common diagnoses linked to MSKDs were “other and unspecified disorders of the back” and “other and unspecified disorders of joints” rendered in 12.7 % and 8.6% persons, respectively
Disability
Large segment of the U.S. work force utilize social services and depends on disability benefits linked to MSKDs
Disability from MSKDs is notable because they reduce both the effective work force and its productivity
Source (1)
13% (34.5 million) of U.S. adults reported difficulty performing routine ADLs because of a medical condition which was a MSKD in 50% of the individuals
Back and neck pain disorders were the most common cause of disability
In individuals over the age of 65 years joint pains and arthritis were the most common cause of disability
Almost 40% of the respondents reported a bed day (1/2 or more days in bed) and 20% reported a lost work day (absence from work in the previous year due to a medical condition), on both occasions the cause was a MSKD in 75% of the cases, far outnumbering all other medical etiologies for lost productivity
Amongst adults in prime working ages (18 to 64 years), 3.6 million individuals reported inability to work and an additional 1.7 million reported limitations in the work they can perform due to chronic back or neck pain
Costs
Costs of MSKDs include direct costs of medical care, and indirect costs from disability, lost wages, disability payments, legal costs and so forth
Source (2)
Average annual costs of MSKDs were $212.7 billion
Average annual direct costs of MSKDs were $82
Average annual indirect costs of MSKDs were $130.7 billion
Higher indirect costs were attributed to the large number of individuals with MSKDs belonging to the active workforce

2.2. Disability

Disability from MSKDs is staggering as they reduce both the effective work force and its productivity (Table 1). In the 2012 NHI Survey 34.5 million U.S. adults (13%) reported significant difficulty performing activities of daily living, which were caused by a MSKD in 50% of the individuals (1). Overall, the back and neck pain disorders were the most common cause of disability except in individuals over the age of 65 years when joint pains were most prevalent (1). Absence from work due to a medical condition was due to a MSKD in 75% of the individuals (1). Chronic back and neck problems were the most common cause of disability amongst adults in prime working ages 18 to 64 years.1

2.3. Costs

Costs related to MSKDs can be categorized as direct costs of medical care and indirect costs such as from lost wages, disability payments, and legal expenses (Table 1) (Appendix 1 in Supplementary File). The U.S. Department of Health and Human Services estimated the average annual costs of MSKDs in 2009 and 2010 as $212.7 billion $82 billion direct costs and $130.7 billion indirect costs (2). The higher indirect costs were attributed to the large number of individuals with MSKDs belonging to the active workforce. Though the direct costs are generally overt the indirect costs are difficult to estimate. For instance, the costs of lost wages are speculative, the disability claims can be fraudulent, and the costs of narcotic use and abuse can only be discursively linked to the MSKDs. To illustrate, a large fraction of workers’ compensation claims related to musculoskeletal injuries, estimated in billions of dollars each year, have been characterized as fraudulent (9). Similarly, in 2012, an estimated 7.7 billion dollars (17%) of the U.S. automotive accident injury related claims were considered as fraudulent (10). Prescription opioids, routinely prescribed to alleviate pain from inadequately treated MSKDs, have significant potential for abuse (11). In 2013, an estimated 1.9 million Americans abused or were dependent on prescription opioids (12). The 2010 yearly costs of prescription opioids were estimated as $129.5 billion $53.4 billion due to nonmedicinal use, $55.7 billion from abuse and dependence, and $20.4 billion were linked to opioid overdoses (13, 14). Notwithstanding the assessment problems some have estimated that the overall recent annual costs of MSKDs in the U.S. are $874 billion 5.7% of the annual U.S. G.D.P. (3).

3. Current Care of Patients with MSKDs

The many reasons for the deficient care of patients with MSKDs can be categorized as: (1) Mutable conditions and the ambiguous sources of pain and disability; (2) disparate care providers and multiple care methodologies; (3) disorderly care and unsystematic referrals; (4) ancillary factors affecting the care choices; (5) non-standardized and ineffective treatments; and (6) inadequate preventative care.

3.1. Mutable Conditions and the Ambiguous Sources of Pain and Disability

Pain and disability stemming from the musculoskeletal system is infrequently due to specific neoplastic, inflammatory or major traumatic lesions and is commonly attributed to, often vague and poorly defined, nonspecific and degenerative conditions (15). As a result, categorizations of the causative pathological processes of many MSKDs remains uncertain and poorly understood. Moreover, these etiological processes are likely heterogeneous and may even be shared for many currently distinct MSKDs. For example, the cellular and matrix dysfunctions of the intervertebral disc (IVD) (16, 17) variably affect the contiguous spinal structures and result in several concurrently present, and currently distinct, clinical syndromes which contribute variably to the patient’s overall symptoms (18). Furthermore, the preponderance of contemporary MSKDs are constellation of clinical findings supported only by a battery of subjective clinical tests and radiological discernments. Few of the broad list of such disorders include spondylosis, non-specific low back pain, discogenic pain, rotator cuff disorders, fibromyalgia, myofascial pain, complex regional pain syndrome, sacroiliac and facet joint syndromes (19-26). Furthermore, the tests employed to validate these syndromes are unable to delineate the precise source of patient’s symptoms, the causative pathological processes remain frequently obscure and often only the aftermaths of these processes are elucidated. For instance, spinal MRI, the gold standard test for the diagnosis of most spinal conditions, is incapable of detecting the primary cellular and matrix IVD dysfunctions (16, 17). The frequent MRI findings of disc herniation, disc desiccation, loss of disc height, disc bulging and spinal stenosis represent mere after effects of the primary disc dysfunctions (27). Additionally, these MRI findings are encountered in symptomatic as well as asymptomatic individuals rendering them less significant (28, 29). Similarly, selective blocks of the various musculoskeletal structures are frequently advocated to determine the precise source of patient’s pain and disability (30). However, not only the results of these blocks are subjective, but they afford no information pertaining to the etiology of patient’s symptoms (31). Overall, the current methods of cataloging pain and dysfunction emanating from the musculoskeletal system are vague, prone to variable interpretations, and the various often concurrently present sources of pain and disability remain regularly obscure despite exhaustive patient evaluations and pertinently employed tests. This methodology also promotes symptomatic approach to treatments and restricts early recognition, prevention, and treatment of the underlying pathological processes. Consequently, the latter often progress relentlessly and cause irreversible damage to the respective musculoskeletal structures with enduring pain and disability (18, 32).

3.2. Disparate Care Providers and Multiple Care Methodologies

In addition to the approximate sources of pain and disability, the care provided to patients with MSKDs is by a broad and heterogeneous group of providers allied to both modern medicine and traditional care. Even though these practitioners pursue dissimilar care methodologies and provide distinct treatments, they assert to treat remarkably similar conditions (Table 2). The broad list of practitioners of modern western medicine treating these conditions include a range of surgeons, physical medicine and rehabilitation (PM&R) physicians, anesthesiologists, neurologists, radiologists, rheumatologists, and physical therapists. The corresponding list of practitioners of traditional and alternative therapies is also exhaustive and include chiropractors, acupuncturists, osteopathic doctors, and massage therapists. Approximately 19,374 orthopedic surgeons, 8,906 PM&R physicians, 4,014 pain medicine specialists (2013), 44,400 chiropractors (2012), and 27,965 acupuncturists (2009) predominantly treated MSKDs in the U.S. (33-35). The curricula and training of the diverse practitioners of modern western medicine is remarkably dissimilar and their scope of practice is often confined to treatment of select spinal, individual joints or soft tissues conditions (36). Similarly, the perspectives of practitioners of traditional medicines are also disparate. For instance, chiropractic and osteopathic treatments are based on assumptions of vertebral misalignments interfering with body’s functions while acupuncture is founded on beliefs of body’s congruence maintained by balance of opposing energies “Yin” and “Yang” of the life force “Qi” (37, 38). Overall, with diverse backgrounds, different treatment philosophies, dissimilar training, and narrow scope of practice, this incongruent group of providers comprehend these disorders differently and offer dissimilar and often conflicting management recommendations for fundamentally the same conditions.

Table 2.

“Conditions Treated” as Listed on Different Specialty Websites (39 - 43)

ChiropracticPhysical TherapyAcupuncturePain SpecialistsOrthopedic Surgeons
Back painBack painRheumatic (rheumatoid) arthritisArthritisACL tear
Carpal tunnelCompression fractureGoutBack painKnee pain
DDDDJDSprainCancer painMeniscal tear
DJDHD disc-related injuriesTennis’ elbowCarpel tunnel syndromePatellar pain
FibromyalgiaNeck painPeriarthritis of shoulderChronic painHip bursitis
HeadachesNerve-compressionLumbar strainCRPSHip pain
OASpondylosisProlapse of lumbar vertebral discDDDPiriformis syndrome
Piriformis SyndromeOsteoporosisCervical spondylopathyDPNDDD
RadiculopathySciaticaStiff neckMuscle injuriesHerniated disc
SciaticaSpinal instabilityMigraine headachesMyofascial painLow back pain
SpondylolisthesisSpinal stenosisNeurosisFibromyalgiaSpinal stenosis
WhiplashSpondylolisthesisNeuralgiaHeadachesTorn disc
SubluxationSprains/strainsSciaticaHerniated discsScoliosis
Car accident injuriesThoracic outlet syndromeNeck painRotator cuff tear
Herniated discWhiplash and post-traumatic injuriesFacial spasmNeuropathyFrozen shoulder
MigrainesDDDFacial paralysisOrofacial painShoulder pain
Sports injuriesChondromalacia patellaThecal cystOsteoporosisShoulder impingent

3.3. Disorderly Care and Un-Systematic Referrals

Coherent patient care rests firmly on accurate choice of providers and smooth transition of care from one provider to the other, practices which result in succinct patterns of referrals. Appropriate and well-timed referrals are critical for the patients with MSKDs as most treatments are beneficial only when provided opportunely in a timely manner. Factors determining referrals amongst generalists and specialists have been expounded upon previously exclusively in primary care settings and were found to be exceedingly complex (44). Even though referrals for infrequent pathological MSKDs such as tumors, inflammatory and traumatic lesions can be obvious, referrals for common degenerative and non-specific conditions, with broad choices of providers treatments and care modalities to choose from, can be daunting. Moreover, though treatment guidelines for select MSKDs are available they are infrequently adhered to (6, 45). Consequently, coordination of care for patients with MSKDs is likely complex and factors determining referrals for these patients have not been systematically studied.

Referrals for patients with MSKDs customarily include initial referrals by the generalists or the patients themselves to the key specialists, typically an orthopedic or neurosurgeon, pain specialist, radiologist, PM&R physician, or a rheumatologist (46). The referral choices by the patients can be direct or indirect by influencing the decisions of the referring providers (47). Many patients, and some generalists, favor initial referrals to traditional and alternative care providers especially chiropractors osteopathic practitioners and acupuncturists citing intuitively the failure of treatments incident to modern western medicine (48). Facing the complex care decisions the generalists and the patients typically rely on the specialists for the ensuing and concomitant care (47, 48). However, most specialists employ predominantly their method of care and may not be abreast with the care rendered by practitioners of other and alternative methodologies (44, 47). In-fact, many specialists disapprove and may even eschew treatments by the rival providers (47). Consequently, the tentative care choices rendered by the generalists and the patients themselves, which are prone to a range of ancillary influences not necessarily linked to the patient care, can profoundly define the care received by these patients. Overall, the referrals provided to a large number of patients with MSKDs lack a systematic approach and depict inconsistent choices of providers and care modalities by the patients, generalists and the specialists alike.

The anomalous choices of care conferred can profoundly affect the costs and the quality of care afforded to these patients. Consulting multiple providers, often with extended wait times, is onerous and can be compounded by despair from dissimilar outlooks and variable treatment recommendations. Justifiably, many patients seek multiple opinions and may resort to unscientific, alternative and traditional methods of treatment (48). These exasperations however are insignificant compared to multiple other disconcerting consequences. For instance, selection of incongruous providers and therapies can result in suitable treatments being denied or not well-timed, delaying, or missing altogether, any opportunities for recovery, and erroneous and superfluous treatments may result in gratuitous complications. The high costs of care in these circumstances can be from unnecessary, extended and repetitive therapies, their complications, and the costs of treating advanced conditions resistant to conventional treatments (49, 50).

One longstanding pattern of referral which must be debated distinctly is the referral of these to orthopedic and spine surgeons. Risk averse in disposition, this practice is likely based on the notion, shared equally by many patients and the generalists, that the preponderance of patients with MSKDs require a surgical treatment (51). Yet, the vast majority of patients with MSKDs require surgery only if expectant or conservative treatments have failed (4). In-fact, inappropriate surgery may exacerbate patient’s symptoms and may culminate in complications (5, 6). Referrals to spine surgeons is frequently provided, often emergently, due to the perceived risk of paralysis. Even though serious neurological deficits from common spinal conditions are infrequent and can be readily identified by pertinent patient evaluation (52). Hence, even though most such referrals can be avoided by enhanced understanding and meticulous patient assessment, spine and orthopedic surgery offices are inundated with patients who ultimately will not require surgery but instead will need suitable triage for their conservative care. Confronted with the cumbersome conservative care triage decisions these patients are often screened, based on variable criteria, by mid-level providers and trainees. Typically, an obligatory number of patients is selected for surgery while a large fraction is categorized as non-surgical candidates (53). At times, due to the overwhelming number of patients conferred at these practices even the choice of surgery may even be ill-suited. For instance, an ardent surgeon may choose to intervene without giving natural recovery a reasonable chance and other similar tenuous incentives may conscript the treatment decisions. Consequently, the seemingly innocuous practice of routine referral of patients with MSKDs to orthopedic and spine surgeons may have unfavorable consequences for many of these patients.

3.4. Ancillary Factors Affecting Care Choices

The unsystematic care conferred is exceedingly susceptible to a host of extraneous influences not necessarily linked to the patient care. By influencing the choice of providers, treatments, methodologies, and the facilities selected, these ancillary factors can markedly, and often adversely, influence the care provided to these patients. Most notable among these are the commercial interests of many care participants including the providers, pharmaceutical companies, equipment makers, hospitals, clinics, and insurance companies. Utilizing diverse media and a contingent of sales personnel these sponsors avidly compete and market their products and services directly to the patients, referring providers, and the facilities (54). However, the endorsements are largely based on anecdotal claims of efficacy and any available research is generally of limited quality, sponsored in nature, or favors the products and services advertised (55). Proprietary and interventional treatments are conspicuously promoted while generic and conservative therapies, even when efficacious, are often ignored (56). “Novel” medical devices are often made promptly available, augmented by the amicable device approval process of the F.D.A. (57). Some providers are inventors, or have patented the interventions and devices, and hence benefit both from the direct use and the overall recommendation of these therapies (58). The third-party payers often deny reimbursements ostensibly due to the lack of necessity. However, these decisions are often rendered without direct patient or provider interaction by company employees with variable backgrounds often unfavorably affecting the care provided to these patients (59). A multitude of other ancillary factors can adversely affect care provided to these patients including procurement of opioids, disability claims and other social, legal, and psychological issues however their comprehensive discussion here would be unwieldy.

3.5. Ineffective and Non-Standardized Treatments

Contemporary treatments for most MSKDs cannot reverse or even apprehend the causative pathological processes and hence are inevitably unsuccessful. A complete review of the mechanisms and efficacy of these treatments is beyond the scope of this article, however, few commonly employed treatments for key MSKDs are briefly discussed (Table 3). Spinal fusion, first described in 1901, is performed universally for a range of spinal conditions with a large number performed for degenerative disc disease and spinal stenosis (60). The number of spinal fusions performed in the U.S. increased from 287,600 in 2001, to 488,300 in 2011 a 70% increase (61). Yet, it does not restore the degenerative disc processes and the multiple outcome studies report persistent pain and disability after the fusion surgery. Moreover, the outcomes degrade proportionate to the number of fusions performed and the vertebral levels fused (49, 62). Similarly, almost half a million discectomies and laminectomies are performed each year in U.S. alone. However, these procedures also do not resolve the degenerative disc processes and may instead accelerate disc degeneration causing long-term pain and disability (50, 61). Persistent pain and disability is common after interventions for many MSKDs but is ubiquitous after spine surgery to a point where distinct ICD-10 codes are assigned expressly to this anomaly (49). Suspected tendinitis and tears of the rotator cuff are the most common shoulder conditions for which patients seek medical attention (20). The number of arthroscopic rotator cuff repair surgeries performed in the U.S. increased from 8/100,000 in 1996, to 58/100,000 in 2006 a 600% increase (63). Yet, these procedures do not ameliorate the antecedent tendon pathologies, are not supported by well-designed studies, and in contrast recent clinical trials show their overall inefficacy (64, 65). Knee osteoarthritis (OA) is the most common arthritic condition and is frequently preceded by meniscal and ligamental knee pathologies (66). Knee arthroscopy is routinely performed for the diagnosis and treatment of knee OA and the precursor meniscal and ligamental conditions (67). In 2006, just in the outpatient settings, 984,607 knee arthroscopies were performed in the U.S. and their number increased by 49% between 1996 and 2006 (68). Yet, these procedures do not alter the pathological course of knee OA, and the multiple outcome studies show that the results of these procedures are similar to sham interventions (67). The intuitive nature of the traditional and alternative modalities including chiropractic, osteopathy, and acupuncture were discussed earlier and despite the abundance of insular literature their efficacy is not evident in the carefully designed studies (69, 70). The lack of effective treatments augmented by the syndrome-based approach to the diagnosis favors symptomatic therapies which henceforth are the mainstay treatments for many MSKDs. The list of these therapies is extensive and only a few can be enumerated:

Medications: Opioids, membrane stabilizers, neurotransmitter re-uptake inhibitors, neuroleptics, muscle relaxers, topical anesthetics, counter irritants;

Physical therapy modalities: Infrared therapies, cryotherapies, braces, traction devices, magnets, mirror therapy, aqua-therapy;

Minimally invasive treatments: Spinal cord and dorsal ganglion stimulation, IDET, X-STOP, MILD procedure;

Psychological therapies: Cognitive behavioral therapy, biofeedback;

And a range of surgeries: Arthroscopic debridements, spinal fusion.

Even when effective, the relief provided by these therapies is often partial and time constrained with ultimate failure of treatments and return of symptoms as the underlying pathological processes inexorable progress and cause irrevocable damage to the related musculoskeletal structures (71). For example, hip and knee arthroplasties are routinely performed for OA affecting the respective joints and are considered highly successful; 427,181 hip and knee arthroplasties were performed between 2012 and 2015 in the U.S. (72). Yet, these surgeries do not arrest the degradation of these joints and their ostensible success is undermined regularly by their time contingent longevity, complications and often the inadequate symptomatic relief (73). Most notable however is the variable perception of these syndromes by the heterogeneous group of providers which results in disparate and remarkably dissimilar treatment strategies. Hence, presented with analogous conditions the choice, timing, and the necessity of the recommended interventions can be markedly different. Compounding these treatment anomalies is the propensity for extended care and repetitive treatments by the individual providers and consequently the therapies are often continued without clear benefits, and sometimes despite adverse effects.

Table 3.

Brief Analysis of Commonly Employed Treatments for Key MSKDs

InterventionDescription and PrevalenceUtility and Efficacy
Spinal fusionFirst described in 1901 and commonly performed for a range of spinal conditions including degenerative disc disease and spinal stenosis (60).Multiple studies continue to report persistent pain and disability after spinal fusion surgery (62).
The number of spinal fusion performed in the U.S. increased from 287,600 in 2001 to 488,300 in 2011 a 70% increase (61).Outcomes degrade with the number of fusions performed and the levels fused.
Discectomy and laminectomyAlmost half a million laminectomies are performed in U.S. each year (61).Both discectomy and laminectomy can cause long-term pain and debility (50).
Rotator cuff surgeryRotator cuff problems are second most common MSKDs after low back pain (74).Lack of well-designed studies supporting these interventions (64).
A 600% increase in rotator cuff surgeries from 1996 to 2006 (63).Recent RCT suggested overall inefficacy of these interventions (65).
Knee arthroscopiesKnees OA is the most common osteoarthritic conditionMultiple outcome studies indicate the results of therapeutic knee arthroscopies similar to sham procedures (67).
Meniscal and ligamental knee injuries frequent precursor to knee OA
Knee arthroscopy routinely performed for these conditions (66).
Number of knee arthroscopies increased by 49% between 1996 and 2006 (68).
Hip and knee arthroplasties427,181 hip and knee arthroplasties performed between 2012 and 2015 (72).Hip and knee arthroplasties are costly, invasive, carry high risk of complications, have durability concerns (73).
Traditional44,400 chiropractors (2012) practicing in the U.S.No scientific basis for these therapies.
Therapies27,965 acupuncturists (2009) practicing in the U.S.Multiple studies indicate lack of their efficacy (69, 70).

3.6. Lack of Preventative Care

A range of genetic predispositions and environmental risk factors play a key role in the inception and perpetuation of most MSKDs (32, 75). Correspondingly, though many musculoskeletal injuries are unintended, and hence unavoidable, the majority are the result of predictable high impact or repetitive insults linked to specific work environments and high-risk lifestyles. Consequently, clear recognition, and augmentation of these risk factors can prevent the majority of MSKDs. For example, OA, the leading cause of pain and disability worldwide, is predisposed to by a variety of environmental risk factors, which include advancing age (76), obesity (77), exposure to high levels of joint loading (78), and previous joint injury (79). Similarly, environmental risk factors play a crucial role in the onset and evolution of most low back and neck pain disorders. The delicate metabolic milieu of the IVD (17) induces it to premature degeneration by a range of risk factors including disproportionate and recurrent disc loading (18), poor posture (80), obesity, and smoking (81). These risk factors are predisposed to by a range of high intensity sports (82) and occupations (83). Similarly, soft tissue injuries to ligaments, tendons, and cartilages, especially those connected to knee, hip and shoulder joints, can cause enduring pain, disability, and culminate in early OA (84-86). Myofascial pain, another common soft tissue-related source of chronic pain, is triggered by postural and other aberrant and repetitive work and lifestyle-related activities (24). Hence a multitude of environmental risk factors linked to lifestyles, work environments, dietary and other individual actions play a crucial role in the inception, propagation and sustainment of most MSKDs. Even though broad preventative measures such as improving dietary habits, reducing obesity, averting sedentary lifestyles, preventing smoking, avoiding high impact and repetitive lifestyle related activities, and mandating apposite work place environments are regularly advocated they are substantiated by insufficient research and hence are at best tenuous (87). Furthermore, whereas tremendous attention is routinely devoted to the advent of exorbitant therapies relatively little consideration is given to develop and institute strategies for the prevention of these conditions (87).

4. Recommendations for Improvement

4.1. Strategies for Prevention, Early Diagnosis, and Treatment

The existing comprehension of the biological dysfunctions responsible for pain and disability linked to the musculoskeletal system must be enhanced. Specifically, future research should further explore the molecular and cellular mechanisms responsible for IVD degeneration, OA, myofascial pain, fibromyalgia, CRPS and the various myofascial, ligamental, and cartilaginous dysfunctions. Explicit understanding of the pathological underpinnings of these disorders may permit their re-cataloging based on etiology and pathology an approach which may facilitate their prevention and early recognition (88). Viable treatments which can emphatically arrest and reverse the causal processes must be conceived. The various national and industry sponsored resources must commit to inquiries pursuing these goals. Clear correlations between the putative etiological factors and the corresponding clinical syndromes must be established and supplant the existing fragile links. Categorical delineation of the causative genetic, acquired, and environmental risk factors would allow exhortation of clear preventative strategies to halt initiation and perpetuation of these conditions. Once expounded these preventative strategies must be emphasized in the perspective management protocols. Screening by non-invasive laboratory biomarker and genetic-based tests, capable of early identification of the causal processes, must eschew the current diagnostic modalities discerning mainly their aftermaths. Adoption of concrete preemptive measures, early recognition of the causal processes, and their timely treatment by disease altering therapies may remedy these conditions before irrevocable destructive changes are cemented and may lessen their staggering toll.

4.2. Strategies for Streamlining Care

Care delivery to patients with MSKDs must be systematic and consistent based on evidence and consensus (89). Management protocols, assessed, scrutinized, approved and propagated by the respective bodies involved in the care of these patients must be adhered to. These management strategies must focus on prevention early and effective treatment and reduced dependence on palliative therapies; especially the opioid medications. The management protocols must also focus on reducing disability, improving function, and on back to work initiatives. A proposal to create a subspecialty of practitioners proficient in all aspects of care of these patients who are not motivated to carry out procedures and interventions may be considered. Providers from disciplines such as family medicine, internal medicine, PM&R and neurology could be trained in comprehensive care of all aspects of MSKDs. These experts could perceptibly compare the various treatment options and make objective and unambiguous care recommendations. For instances, suggestions for a specific physical therapy modality, injection, minimally invasive intervention, or a surgical option must be clear. These providers must also provide uninterrupted treatment surveillance as the conditions evolve procure services of additional specialists when necessary and determine the precise activity and work restrictions.

4.3. Policy Recommendations

To reduce the impact of ancillary factors reimbursements for new interventions could be limited to those endorsed by a panel of independent experts not directly linked to their procurement or development. Similarly, the ongoing use of various therapies, interventions, and devices could be monitored and those not supported by contemporaneous research could be re-evaluated. The off-label use of the devices and drugs must be scrutinized denoted as experimental and supported only by investigational resources. The influx of commercially motivated interventions can be confined by adhering to evidenced and consensus-based approach discussed above and by oversight of the promotional materials and marketing strategies. Use of unscientific therapies could be limited or at a minimum the users warned of their unscientific nature potential dangers and lack of efficacy. Congruently, rejection of reimbursements for rigorously evaluated and endorsed treatments should be discouraged, and any suspected disproportionate or inappropriate use of these treatments, and tests, can be disclosed to and investigated by the pertinent agencies.

5. Conclusions

Musculoskeletal disorders are a chief source of pain and disability. This article attempts to highlight the significant problems with the care of patients with musculoskeletal disorders citing their care in the U.S. as an example. However, these problems are global in scope. The observations and the preliminary recommendations made in this article may help improve the overall care of patients with MSKDs and may reduce the global incidence of unscathed pain and disability.

References

  • 1.

    Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National health interview survey, 2012. Vital Health Stat. 2014;(260):1-161. [PubMed ID: 24819891].

  • 2.

    Medical Expenditures Panel Survey (MEPS). Agency for Healthcare Research and Quality, U.S. Department of Health & Human Services. 2018. Available from: http://meps.ahrq.gov/mepsweb/.

  • 3.

    Weinstein S, Yelin E. The burden of musculoskeletal diseases in the United States. 2018. Available from: http://www.boneandjointburden.org/.

  • 4.

    Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-81. [PubMed ID: 23896698]. [PubMed Central ID: PMC4381435]. https://doi.org/10.1001/jamainternmed.2013.8992.

  • 5.

    Lubelski D, Williams SK, O'Rourke C, Obuchowski NA, Wang JC, Steinmetz MP, et al. Differences in the surgical treatment of lower back pain among spine surgeons in the United States. Spine (Phila Pa 1976). 2016;41(11):978-86. [PubMed ID: 26679881]. https://doi.org/10.1097/BRS.0000000000001396.

  • 6.

    Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-94. [PubMed ID: 20602122]. [PubMed Central ID: PMC2997201]. https://doi.org/10.1007/s00586-010-1502-y.

  • 7.

    Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. 2011. Available from: www.hcup-us.ahrq.gov/nisoverview.jsp.

  • 8.

    National Center for Health Statistics. Center for Disease Control and Prevention. 2010. Available from: www.cdc.gov/nchs/nhds/nhds_questionnaires.htm.

  • 9.

    Wertz K, Bryant JJ. Managing workers' compensation: A guide to injury reduction and effective claim management. CRC Press; 2000.

  • 10.

    Insurance Research Council. Insurance research council finds that fraud and buildup add up to 7.7 billion USD in excess payments for auto injury claims. 2015. Available from: https://www.insurance-research.org/sites/default/files/downloads/IRC%20Fraud%20News%20Release.pdf.

  • 11.

    Phillips JK, Ford MA; National Academies of Sciences Engineering and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse, et al. Pain management and the intersection of pain and opioid use disorder. In: Bonnie RJ, editor. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use. Washington (DC): National Academies Press; 2017.

  • 12.

    US Department of Health and Human Services Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Results from the 2013 national survey on drug use and health: Summary of national findings. Rockville, MD: SAMHSA Publications; 2014.

  • 13.

    Inocencio TJ, Carroll NV, Read EJ, Holdford DA. The economic burden of opioid-related poisoning in the United States. Pain Med. 2013;14(10):1534-47. [PubMed ID: 23841538]. https://doi.org/10.1111/pme.12183.

  • 14.

    Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16(8):769-80. [PubMed ID: 26028573]. [PubMed Central ID: PMC4562413]. https://doi.org/10.1016/j.jpain.2015.05.002.

  • 15.

    Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988;318(5):291-300. [PubMed ID: 2961994]. https://doi.org/10.1056/NEJM198802043180506.

  • 16.

    Wang F, Cai F, Shi R, Wang XH, Wu XT. Aging and age related stresses: A senescence mechanism of intervertebral disc degeneration. Osteoarthritis Cartilage. 2016;24(3):398-408. [PubMed ID: 26455958]. https://doi.org/10.1016/j.joca.2015.09.019.

  • 17.

    Holm S, Maroudas A, Urban JP, Selstam G, Nachemson A. Nutrition of the intervertebral disc: Solute transport and metabolism. Connect Tissue Res. 1981;8(2):101-19. [PubMed ID: 6453689].

  • 18.

    Buckwalter JA, Mow VC, Boden SD, Eyre DR, Weidenbaum M. Intervertebral disk structure, composition, and mechanical function. In: Buckwalter JA, Einhorn TA, Simon SR, editors. Orthopaedic basic science-biology and biomechanics of the musculoskeletal system. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2000. p. 548-55.

  • 19.

    Middleton K, Fish DE. Lumbar spondylosis: Clinical presentation and treatment approaches. Curr Rev Musculoskelet Med. 2009;2(2):94-104. [PubMed ID: 19468872]. [PubMed Central ID: PMC2697338]. https://doi.org/10.1007/s12178-009-9051-x.

  • 20.

    Zelle BA, Gruen GS, Brown S, George S. Sacroiliac joint dysfunction: Evaluation and management. Clin J Pain. 2005;21(5):446-55. [PubMed ID: 16093751].

  • 21.

    van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. Pain originating from the lumbar facet joints. Pain Pract. 2010;10(5):459-69. [PubMed ID: 20667027]. https://doi.org/10.1111/j.1533-2500.2010.00393.x.

  • 22.

    Malik KM, Cohen SP, Walega DR, Benzon HT. Diagnostic criteria and treatment of discogenic pain: A systematic review of recent clinical literature. Spine J. 2013;13(11):1675-89. [PubMed ID: 23993035]. https://doi.org/10.1016/j.spinee.2013.06.063.

  • 23.

    Gomoll AH, Katz JN, Warner JJ, Millett PJ. Rotator cuff disorders: recognition and management among patients with shoulder pain. Arthritis Rheum. 2004;50(12):3751-61. [PubMed ID: 15593187]. https://doi.org/10.1002/art.20668.

  • 24.

    Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004;14(1):95-107. [PubMed ID: 14759755]. https://doi.org/10.1016/j.jelekin.2003.09.018.

  • 25.

    Hauser W, Ablin J, Fitzcharles MA, Littlejohn G, Luciano JV, Usui C, et al. Fibromyalgia. Nat Rev Dis Primers. 2015;1:15022. [PubMed ID: 27189527]. https://doi.org/10.1038/nrdp.2015.22.

  • 26.

    Urits I, Shen AH, Jones MR, Viswanath O, Kaye AD. Complex regional pain syndrome, current concepts and treatment options. Curr Pain Headache Rep. 2018;22(2):10. [PubMed ID: 29404787]. https://doi.org/10.1007/s11916-018-0667-7.

  • 27.

    Simon J, McAuliffe M, Shamim F, Vuong N, Tahaei A. Discogenic low back pain. Phys Med Rehabil Clin N Am. 2014;25(2):305-17. [PubMed ID: 24787335]. https://doi.org/10.1016/j.pmr.2014.01.006.

  • 28.

    Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(8):1178-84. [PubMed ID: 2398088].

  • 29.

    Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69-73. [PubMed ID: 8208267]. https://doi.org/10.1056/NEJM199407143310201.

  • 30.

    Datta S, Manchikanti L, Falco FJ, Calodney AK, Atluri S, Benyamin RM, et al. Diagnostic utility of selective nerve root blocks in the diagnosis of lumbosacral radicular pain: Systematic review and update of current evidence. Pain Physician. 2013;16(2 Suppl):SE97-124. [PubMed ID: 23615888].

  • 31.

    Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain. 1995;11(3):208-13. [PubMed ID: 8535040].

  • 32.

    Glyn-Jones S, Palmer AJ, Agricola R, Price AJ, Vincent TL, Weinans H, et al. Osteoarthritis. Lancet. 2015;386(9991):376-87. [PubMed ID: 25748615]. https://doi.org/10.1016/S0140-6736(14)60802-3.

  • 33.

    [No Authors Listed]. Association of American Medical Colleges (AAMC),. 2018. Available from: https://members.aamc.org/eweb/upload/2017%20State%20Physician%20Workforce%20Data%20Report.pdf.

  • 34.

    [No Authors Listed]. United States Department of Labor. 2012. Available from: https://www.bls.gov/bls/budget2012_enacted.htm.

  • 35.

    [No Authors Listed]. People's Organization of Community Acupuncture (POCA),. 2009. Available from: https://www.pocacoop.com/.

  • 36.

    Monrad SU, Zeller JL, Craig CL, DiPonio LA. Musculoskeletal education in US medical schools: Lessons from the past and suggestions for the future. Cur Rev Mus Med. 2011;4(3):91. https://doi.org/10.1007/s12178-011-9083.

  • 37.

    Keating J. A brief history of the chiropractic profession. In: Haldeman S, Dagenais S, Budgell B, editors. Principles and practice of chiropractic. 3rd ed. McGraw Hill Professional; 2005. p. 23-64.

  • 38.

    White A, Ernst E. A brief history of acupuncture. Rheumatology (Oxford). 2004;43(5):662-3. [PubMed ID: 15103027]. https://doi.org/10.1093/rheumatology/keg005.

  • 39.

    HOFF Chiropractic Clinic. Medical Conditions Chiropractors Treat. 2018. Available from: http://www.hoffchiropractic.com/medical-conditions.

  • 40.

    [No Authors Listed]. Walker Physical Therapy and Pain Center. 2014. Available from: http://www.walkerpt.com/walker-physical-therapy-pain-center-services/spine-conditions-treated-physical-therapy.

  • 41.

    [No Authors Listed]. Acupuncture Columbus. 2018. Available from: http://www.acupuncturecolumbus.com/conditions-commonly-treated.

  • 42.

    [No Authors Listed]. Pain Management Center. 2018. Available from: https://www.painmanagementctr.com/conditions-treated.

  • 43.

    [No Authors Listed]. Aurora Health Care. 2018. Available from: https://www.aurorahealthcare.org/services/orthopedics/conditions.

  • 44.

    Bodenheimer T. Coordinating care--a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064-71. [PubMed ID: 18322289]. https://doi.org/10.1056/NEJMhpr0706165.

  • 45.

    Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, part I: Critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. 2007;15(9):981-1000. [PubMed ID: 17719803]. https://doi.org/10.1016/j.joca.2007.06.014.

  • 46.

    Solomon DH, Bates DW, Schaffer JL, Horsky J, Burdick E, Katz JN. Referrals for musculoskeletal disorders: Patterns, predictors, and outcomes. J Rheumatol. 2001;28(9):2090-5. [PubMed ID: 11550979].

  • 47.

    Brekke KR, Gravelle H, Siciliani L, Straume OR. Patient choice, mobility and competition among health care providers. Health Care Provision Patient Mobility. 2014:1-26. https://doi.org/10.1007/978-88-470-5480-6_1.

  • 48.

    Sibbritt D, Lauche R, Sundberg T, Peng W, Moore C, Broom A, et al. Severity of back pain may influence choice and order of practitioner consultations across conventional, allied and complementary health care: A cross-sectional study of 1851 mid-age Australian women. BMC Musculoskelet Disord. 2016;17(1):393. [PubMed ID: 27639556]. [PubMed Central ID: PMC5026776]. https://doi.org/10.1186/s12891-016-1251-0.

  • 49.

    Fritsch EW, Heisel J, Rupp S. The failed back surgery syndrome: Reasons, intraoperative findings, and long-term results: A report of 182 operative treatments. Spine (Phila Pa 1976). 1996;21(5):626-33. [PubMed ID: 8852320].

  • 50.

    Parker SL, Mendenhall SK, Godil SS, Sivasubramanian P, Cahill K, Ziewacz J, et al. Incidence of low back pain after lumbar discectomy for herniated disc and its effect on patient-reported outcomes. Clin Orthop Relat Res. 2015;473(6):1988-99. [PubMed ID: 25694267]. [PubMed Central ID: PMC4419014]. https://doi.org/10.1007/s11999-015-4193-1.

  • 51.

    Blackston JW, Bouldin MJ, Brown CA, Duddleston DN, Hicks GS, Holman HE. Malpractice risk prevention for primary care physicians. Am J Med Sci. 2002;324(4):212-9. [PubMed ID: 12385494].

  • 52.

    Nordin M, Randhawa K, Torres P, Yu H, Haldeman S, Brady O, et al. The Global Spine Care Initiative: A systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018;27(Suppl 6):816-27. [PubMed ID: 29492717]. https://doi.org/10.1007/s00586-017-5446-3.

  • 53.

    Busse JW, Riva JJ, Nash JV, Hsu S, Fisher CG, Wai EK, et al. Surgeon attitudes toward nonphysician screening of low back or low back-related leg pain patients referred for surgical assessment: A survey of Canadian spine surgeons. Spine (Phila Pa 1976). 2013;38(7):E402-8. [PubMed ID: 23324924]. https://doi.org/10.1097/BRS.0b013e318286c96b.

  • 54.

    Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 2008;8(1):1-7. [PubMed ID: 18164448]. https://doi.org/10.1016/j.spinee.2007.10.009.

  • 55.

    Khan SN, Mermer MJ, Myers E, Sandhu HS. The roles of funding source, clinical trial outcome, and quality of reporting in orthopedic surgery literature. Am J Orthop (Belle Mead NJ). 2008;37(12):E205-12. discussion E212. [PubMed ID: 19212579].

  • 56.

    Kesselheim AS, Avorn J, Sarpatwari A. The high cost of prescription drugs in the United States: Origins and prospects for reform. JAMA. 2016;316(8):858-71. [PubMed ID: 27552619]. https://doi.org/10.1001/jama.2016.11237.

  • 57.

    Galgon RE. Understanding medical device regulation. Curr Opin Anaesthesiol. 2016;29(6):703-10. [PubMed ID: 27585362]. https://doi.org/10.1097/ACO.0000000000000391.

  • 58.

    Radder H. Exploiting abstract possibilities: A critique of the concept and practice of product patenting. J Agric Environ Ethics. 2004;17(3):275-91. [PubMed ID: 15543679].

  • 59.

    Cheng JS, Lee MJ, Massicotte E, Ashman B, Gruenberg M, Pilcher LE, et al. Clinical guidelines and payer policies on fusion for the treatment of chronic low back pain. Spine (Phila Pa 1976). 2011;36(21 Suppl):S144-63. [PubMed ID: 21952186]. https://doi.org/10.1097/BRS.0b013e31822ef5b4.

  • 60.

    Memtsoudis SG, Vougioukas VI, Ma Y, Gaber-Baylis LK, Girardi FP. Perioperative morbidity and mortality after anterior, posterior, and anterior/posterior spine fusion surgery. Spine (Phila Pa 1976). 2011;36(22):1867-77. [PubMed ID: 20453725]. [PubMed Central ID: PMC2921012]. https://doi.org/10.1097/BRS.0b013e3181c7decc.

  • 61.

    Agency for Healthcare Research and Quality (AHRQ). Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample (NIS). 2001-2011.

  • 62.

    Ma Y, Passias P, Gaber-Baylis LK, Girardi FP, Memtsoudis SG. Comparative in-hospital morbidity and mortality after revision versus primary thoracic and lumbar spine fusion. Spine J. 2010;10(10):881-9. [PubMed ID: 20869002]. [PubMed Central ID: PMC2946947]. https://doi.org/10.1016/j.spinee.2010.07.391.

  • 63.

    Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-33. [PubMed ID: 22298054]. [PubMed Central ID: PMC3262185]. https://doi.org/10.2106/JBJS.J.00739.

  • 64.

    Dorrestijn O, Stevens M, Winters JC, van der Meer K, Diercks RL. Conservative or surgical treatment for subacromial impingement syndrome? A systematic review. J Shoulder Elbow Surg. 2009;18(4):652-60. [PubMed ID: 19286397]. https://doi.org/10.1016/j.jse.2009.01.010.

  • 65.

    Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): A multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-38. [PubMed ID: 29169668]. [PubMed Central ID: PMC5803129]. https://doi.org/10.1016/S0140-6736(17)32457-1.

  • 66.

    Murphy L, Schwartz TA, Helmick CG, Renner JB, Tudor G, Koch G, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59(9):1207-13. [PubMed ID: 18759314]. [PubMed Central ID: PMC4516049]. https://doi.org/10.1002/art.24021.

  • 67.

    Katz JN, Brownlee SA, Jones MH. The role of arthroscopy in the management of knee osteoarthritis. Best Pract Res Clin Rheumatol. 2014;28(1):143-56. [PubMed ID: 24792949]. [PubMed Central ID: PMC4010873]. https://doi.org/10.1016/j.berh.2014.01.008.

  • 68.

    Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: A comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am. 2011;93(11):994-1000. [PubMed ID: 21531866]. https://doi.org/10.2106/JBJS.I.01618.

  • 69.

    Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low back pain: An update of the cochrane review. Spine (Phila Pa 1976). 2013;38(3):E158-77. [PubMed ID: 23169072]. https://doi.org/10.1097/BRS.0b013e31827dd89d.

  • 70.

    Paterson C, Dieppe P. Characteristic and incidental (placebo) effects in complex interventions such as acupuncture. BMJ. 2005;330(7501):1202-5. [PubMed ID: 15905259]. [PubMed Central ID: PMC558023]. https://doi.org/10.1136/bmj.330.7501.1202.

  • 71.

    Hunter DJ. Pharmacologic therapy for osteoarthritis--the era of disease modification. Nat Rev Rheumatol. 2011;7(1):13-22. [PubMed ID: 21079644]. https://doi.org/10.1038/nrrheum.2010.178.

  • 72.

    American Joint Replacement Registry. Third AJRR annual report on hip and knee arthroplasty data. 2016. Available from: http://www.ajrr.net/images/annual_reports/AJRR_2016_Annual_Report_final.pdf.

  • 73.

    Chang RW, Pellisier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. 1996;275(11):858-65. [PubMed ID: 8596224].

  • 74.

    Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: Prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003;102(1-2):167-78. [PubMed ID: 12620608].

  • 75.

    Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervical and lumbar disc degeneration: A magnetic resonance imaging study in twins. Arthritis Rheum. 1999;42(2):366-72. [PubMed ID: 10025932]. https://doi.org/10.1002/1529-0131(199902)42:2<366::AID-ANR20>3.0.CO;2-6.

  • 76.

    Dillon CF, Rasch EK, Gu Q, Hirsch R. Prevalence of knee osteoarthritis in the United States: Arthritis data from the Third National Health and Nutrition Examination Survey 1991-94. J Rheumatol. 2006;33(11):2271-9. [PubMed ID: 17013996].

  • 77.

    Anderson JJ, Felson DT. Factors associated with osteoarthritis of the knee in the first national health and nutrition examination survey (HANES I). Evidence for an association with overweight, race, and physical demands of work. Am J Epidemiol. 1988;128(1):179-89. [PubMed ID: 3381825].

  • 78.

    Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization. Arthritis Rheum. 1995;38(8):1134-41. [PubMed ID: 7639811].

  • 79.

    Blagojevic M, Jinks C, Jeffery A, Jordan KP. Risk factors for onset of osteoarthritis of the knee in older adults: A systematic review and meta-analysis. Osteoarthritis Cartilage. 2010;18(1):24-33. [PubMed ID: 19751691]. https://doi.org/10.1016/j.joca.2009.08.010.

  • 80.

    Teichtahl AJ, Urquhart DM, Wang Y, Wluka AE, O'Sullivan R, Jones G, et al. Physical inactivity is associated with narrower lumbar intervertebral discs, high fat content of paraspinal muscles and low back pain and disability. Arthritis Res Ther. 2015;17:114. [PubMed ID: 25947906]. [PubMed Central ID: PMC4422596]. https://doi.org/10.1186/s13075-015-0629-y.

  • 81.

    Deyo RA, Bass JE. Lifestyle and low-back pain. The influence of smoking and obesity. Spine (Phila Pa 1976). 1989;14(5):501-6. [PubMed ID: 2524888].

  • 82.

    Rozan M, Rouhollahi V, Rastogi A, Dureha DK. Influence of physiological loading on the lumbar spine of national level athletes in different sports. J Hum Kinet. 2016;50:115-23. [PubMed ID: 28149348]. [PubMed Central ID: PMC5260646]. https://doi.org/10.1515/hukin-2015-0148.

  • 83.

    McGill SM. The biomechanics of low back injury: Implications on current practice in industry and the clinic. J Biomech. 1997;30(5):465-75. [PubMed ID: 9109558].

  • 84.

    Dale KM, Bailey JR, Moorman CT 3rd. Surgical management and treatment of the anterior cruciate ligament/medial collateral ligament injured knee. Clin Sports Med. 2017;36(1):87-103. [PubMed ID: 27871663]. https://doi.org/10.1016/j.csm.2016.08.005.

  • 85.

    Pandey V, Jaap Willems W. Rotator cuff tear: A detailed update. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(1):1-14. [PubMed ID: 29264234]. [PubMed Central ID: PMC5730646]. https://doi.org/10.1016/j.asmart.2014.11.003.

  • 86.

    Beaufils P, Becker R, Kopf S, Englund M, Verdonk R, Ollivier M, et al. Surgical management of degenerative meniscus lesions: The 2016 ESSKA meniscus consensus. Joints. 2017;5(2):59-69. [PubMed ID: 29114633]. [PubMed Central ID: PMC5672871]. https://doi.org/10.1055/s-0037-1603813.

  • 87.

    Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. Prevention of low back pain: A systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199-208. [PubMed ID: 26752509]. https://doi.org/10.1001/jamainternmed.2015.7431.

  • 88.

    Khan TW, Imani F. The management of chronic pain; caught between a rock and a hard place: The Case for a renewed focus on provider, patient, and payer education. Anesth Pain Med. 2017;7(1). e40951. [PubMed ID: 28920037]. [PubMed Central ID: PMC5554427]. https://doi.org/10.5812/aapm.40951.

  • 89.

    Imani F, Rahimzadeh P. Interventional pain management according to evidence-based medicine. Anesth Pain Med. 2012;1(4):235-6. [PubMed ID: 24904805]. [PubMed Central ID: PMC4018708]. https://doi.org/10.5812/aapm.4514.