Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools?

BACKGROUND: Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. METHODS: The amount of time spent on musculoskeletal education at each of Canada's medical schools was reviewed by surveying the directors (or equivalents) of all sixteen undergraduate musculoskeletal programs. With use of data from this survey and the Association of American Medical Colleges' guide to curricula, the percentage of the total curriculum devoted to musculoskeletal education was determined. The prevalence of disorders related to the musculoskeletal system among patients of primary care physicians was determined on an international basis by reviewing the literature and on a local basis by surveying all primary care physicians affiliated with the University of British Columbia's Department of Family Medicine. RESULTS: The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. The questionnaires completed by the directors of the undergraduate programs indicated widespread dissatisfaction with the musculoskeletal education process and, specifically, with the amount of time devoted to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. CONCLUSION: There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.     

The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopaedic surgery residency programs

BACKGROUND: Orthopaedic residency programs lack gender and race diversity. This study examines the hypothesis that exposure to a required course in musculoskeletal medicine in medical school is associated with a higher rate of application to orthopaedic surgery residency programs by underrepresented groups. METHODS: All 122 medical schools in the United States were surveyed in 2001 to determine whether they required dedicated course work in musculoskeletal medicine, defined as a preclinical module or clinical clerkship in orthopaedic surgery, rheumatology, or physiatry. Data from the Electronic Residency Application Service were obtained for the class of 2002. From these two sources, the rate of applications from students to orthopaedic surgery residency programs was calculated as a function of exposure to a required course in musculoskeletal medicine. Subgroup analysis was further carried out for women and for African Americans, Latinos, and Native Americans. RESULTS: In 2002, there were 16,294 graduates of American medical schools, of whom approximately 55% had mandatory instruction in musculoskeletal medicine. The rate of application to orthopaedic surgery residency programs was 5.7% among the students with required instruction compared with a rate of 5.1% for students without such required instruction. The rate of application for female students was 2.0% for those who had required courses and 1.1% for the female students who had not had the required courses. The rate of application for minority students in schools with required courses was 8.2% compared with a rate of 6.1% for those students without such exposure. CONCLUSIONS: Required instruction in musculoskeletal medicine was associated with a 12% higher rate of application to orthopaedic surgery residency programs among all students (5.7% of those who received required instruction compared with 5.1% of those who did not). The relative difference was more pronounced among women (a 75% difference in the rate of application) and minorities (a 35% difference in the rate of application). This study suggests that required instruction in musculoskeletal medicine can help to promote diversity in orthopaedic surgery residency programs.     

Association of sleep quality and chronification of musculoskeletal pain in an older adult: A case report

BackgroundSleep disorders and chronic musculoskeletal pain are highly prevalent conditions that are often comorbid clinically. The role of sleep disorder on the chronification of musculoskeletal pain is well documented, although the mechanisms have not yet been fully established.ObjectivesHere we present a case study demonstrating the clinical comorbidity of sleep disorder with chronification of musculoskeletal pain in an older adult with clinical history of hypothyroidism. The aim of this case is to highlight important risk factors of age, gender and hypothyroidism, which the clinician should be aware of for their potential contributory role in the development of sleep disorder and chronification of musculoskeletal pain.Clinical featuresPatient presented with a flare-up of pain in right shoulder and neck that had been intermittently present for several years but of which the intensity had become increasingly worse over time. The patient was diagnosed with chronic right rotator cuff tendonitis and a grade III supraspinatus tear. Clinical history revealed that significant sleep disorder and hypothyroidism were also present in this case.Intervention and outcomesTreatment focused on relieving pain and restoring function to the right shoulder. Interventions including passive mobilization, manual ischemic trigger point therapy, and passive traction were applied. Patient also provided with diaphragmatic breathing exercises to help alleviate her sleep disorder. After 12 weeks patient reported decreased pain levels and improved ROM of the right shoulder. Patient also reported improved sleep, both in quality and quantity.ConclusionThis case demonstrates the importance of considering the association between sleep disorder and the chronification of musculoskeletal pain in older adults. This study highlights common potential risk factors of age, gender and hypothyroidism which may contribute to the development of these conditions in older patients.     

The Burden of Musculoskeletal Disease in Sierra Leone

BackgroundMusculoskeletal disease is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in developing countries are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure the incidence and prevalence of surgically treatable conditions, including musculoskeletal conditions, in patients in low- and middle-income countries, and was administered in the West African nation of Sierra Leone in 2012.PurposeWe attempted to quantify the burden of potentially treatable musculoskeletal conditions in patients in Sierra Leone.MethodsA cross-sectional two-stage cluster-based survey was performed in Sierra Leone using the SOSAS. Two individuals from each randomly selected household underwent a verbal head to toe examination. The musculoskeletal-related questions from the SOSAS survey in Sierra Leone were analyzed to determine the prevalence of musculoskeletal problems in the study population. Prevalence is reported as the number of respondents with a musculoskeletal problem now and number of respondents with a musculoskeletal problem during the past year. Respondents had “no need” for care, they “received care”, or they faced a barrier that prevented them from receiving care.ResultsOne thousand eight hundred seventy-five households were targeted, with 1843 undergoing the survey, which yielded 3645 individual respondents. Of the individual respondents, 462 (n = 3645; 12.6% of total; 95% CI, 12%–13%) had a traumatic musculoskeletal problem during the past year, and 236 (n = 3645; 6% of total; 95% CI, 5%–7%) respondents had a musculoskeletal problem of nontraumatic etiology. Of respondents with either a traumatic or nontraumatic musculoskeletal problem, 359 (n = 562; 63.9% of total; 95% CI, 59.5–68.3%) needed care but were unable to receive it with the major barrier reported as financial.ConclusionResource allocation decisions in global health are made based on burden of disease data in low- and middle-income countries. The data provided here for Sierra Leone may offer some generalizable insight into the scope of the burden of musculoskeletal disease for low- and middle-income countries, especially in Sub-Saharan Africa, and provide concrete evidence that musculoskeletal health should be included in the global health discussion. However, there may be important differences across countries in this region, and further study to elucidate these differences seems critical given the large burden of disease and the limited resources available in these regions to manage it.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-4017-8) contains supplementary material, which is available to authorized users.     

Assessment of musculoskeletal knowledge in primary care residents

We assessed musculoskeletal training in primary care residency programs at the University of Arizona to determine whether formal orthopedic instruction increased musculoskeletal knowledge. The University of Pennsylvania Basic Competency Examination in Musculoskeletal Medicine was administered to 38 of 52 primary care resident volunteers. The established "passing" score to demonstrate basic competency on this test is 73.1%. The overall score of the residents tested was 56.3% (range, 21%-88%). Eight of 38 residents had a score of 73.1% or higher. The mean scores were 61.5% with orthopedic rotation and 47.3% without orthopedic rotation. The difference was statistically significant (P=.05). Pediatric residents had the least exposure to musculoskeletal training, and none of them "passed" the competency examination. Primary care providers have a larger role in managing musculoskeletal problems with current managed health care systems in the United States. Many primary care residency programs do not provide adequate training in musculoskeletal medicine. The majority of exiting primary care residents do not have basic competency in managing musculoskeletal problems. Our study results show that residents who take an orthopedic rotation have a larger knowledge base. It seems reasonable to increase primary care residents' formal education regarding musculoskeletal problems.     

Extremity injuries in children resulting from the 1999 Marmara earthquake: an epidemiologic study

The purpose of this study was to determine the clinical features, type and severity of musculoskeletal injuries in paediatric age groups in comparison with adult victims of the Marmara earthquake, which occurred on 17 August 1999. Of 151 injured patients hospitalized due to musculoskeletal trauma, 31 (20.5%) were under 16 years of age. The most important problems in the patients were extremity trauma, crush syndrome, acute renal failure and other ensuing medical complications. Five (18.5%) out of 27 children with crush syndrome required haemodialysis because of acute renal failure and three (11.1%) required amputation. Haemodialysis was needed in 54 (93.1%) of 58 adult patients with crush syndrome; amputation was necessary in 12 (20.7%) of them. Although the types of injuries resulting from the earthquake were similar in adults and children, the orthopaedic consequences of these injuries showed significant differences, especially in the rates of crush syndrome leading to acute renal failure and amputation.     

Preliminary validation of clinical assessment for deep vein thrombosis in orthopaedic outpatients

The purpose of our study was to determine if a previously published clinical decision rule designed to estimate the probability of proximal deep vein thrombosis in outpatients is valid when applied exclusively to outpatients with musculoskeletal disorders. We also sought to determine whether probability estimates differed for patients with or without trauma, fracture, or recent orthopaedic surgery. Data collected from outpatients with surgical and nonsurgical musculoskeletal disorders (n = 464) were extracted from the datasets of three previously published studies done on heterogeneous groups of patients (n = 3424). Followup for all patients was 3 months. Testing of all patients for thromboembolic disease was done using validated diagnostic procedures. Probability estimates for orthopaedic outpatients were consistent with estimates from published studies. The proportion of patients who had venous thromboembolism was 5.6% (95% confidence interval, 3.5-8.7%) for the low probability group, 14.1% (95% confidence interval, 8.6-22.4%) for the moderate probability group, and 47.4% (95% confidence interval, 35.3-60%) for the high probability group. Validity estimates for patients with and without recent trauma, surgery, or fracture differed, but not dramatically. The validity of the clinical decision rule as applied to outpatients with musculoskeletal disorders was supported.     

The Short Musculoskeletal Function Assessment Questionnaire (SMFA)Cross-cultural adaptation,validity, reliability and responsiveness of the Swedish SMFA (SMFA-Swe)

The Short Musculoskeletal Function Assessment Questionnaire (SMFA) is designed to measure the functional status of patients with a broad range of musculoskeletal injuries and disorders. It has previously been validated for an American population. We have translated the SMFA into Swedish and tested the translated version (SMFA-Swe) as regards validity, reliability and responsiveness. Acute and elective cases (n= 298) were included in the study. The Swedish version of the SF-36 was used in the validation. We found that the SMFA-Swe was easy to use, that its reliability (internal consistency and stability) was good, that it correlated well with the SF-36 physical scores and that it was also sensitive to changes in musculoskeletal function over time. Orthopedic studies frequently use disease-specific outcome measures because they are sensitive to the disorder studied. However, there may also be a need to evaluate function in groups of patients with different or multiple musculoskeletal disorders and, in such situations, the SMFA can be useful. We conclude that the SMFA-Swe is a valid instrument and can be used in clinical research as well as clinical practice when focusing on patients with various musculoskeletal disorders.     

The Short Musculoskeletal Function Assessment Questionnaire (SMFA): cross-cultural adaptation, validity, reliability and responsiveness of the Swedish SMFA (SMFA-Swe)

The Short Musculoskeletal Function Assessment Questionnaire (SMFA) is designed to measure the functional status of patients with a broad range of musculoskeletal injuries and disorders. It has previously been validated for an American population. We have translated the SMFA into Swedish and tested the translated version (SMFA-Swe) as regards validity, reliability and responsiveness. Acute and elective cases (n = 298) were included in the study. The Swedish version of the SF-36 was used in the validation. We found that the SMFA-Swe was easy to use, that its reliability (internal consistency and stability) was good, that it correlated well with the SF-36 physical scores and that it was also sensitive to changes in musculoskeletal function over time. Orthopedic studies frequently use disease-specific outcome measures because they are sensitive to the disorder studied. However, there may also be a need to evaluate function in groups of patients with different or multiple musculoskeletal disorders and, in such situations, the SMFA can be useful. We conclude that the SMFA-Swe is a valid instrument and can be used in clinical research as well as clinical practice when focusing on patients with various musculoskeletal disorders.     

Analyzing musculoskeletal neck pain, measured as present pain and periods of pain, with three different regression models: a cohort study

Background  

In the literature there are discussions on the choice of outcome and the need for more longitudinal studies of musculoskeletal disorders. The general aim of this longitudinal study was to analyze musculoskeletal neck pain, in a group of young adults. Specific aims were to determine whether psychosocial factors, computer use, high work/study demands, and lifestyle are long-term or short-term factors for musculoskeletal neck pain, and whether these factors are important for developing or ongoing musculoskeletal neck pain.     

Cervical muscle dysfunction in the chronic whiplash associated disorder grade II (WAD-II)

STUDY DESIGN: In a cross-sectional study, surface electromyography measurements of the upper trapezius muscles were obtained during different functional tasks in patients with a chronic whiplash associated disorder Grade II and healthy control subjects. OBJECTIVES: To investigate whether muscle dysfunction of the upper trapezius muscles, as assessed by surface electromyography, can be used to distinguish patients with whiplash associated disorder Grade II from healthy control subjects. SUMMARY OF BACKGROUND INFORMATION: In the whiplash associated disorder, there is need to improve the diagnostic tools. Whiplash associated disorder Grade II is characterized by the presence of "musculoskeletal signs." Surface electromyography to assess these musculoskeletal signs objectively may be a useful tool. METHODS: Normalized smoothed rectified electromyography levels of the upper trapezius muscles of patients with whiplash associated disorder Grade II (n = 18) and healthy control subjects (n = 19) were compared during three static postures, during a unilateral dynamic manual exercise, and during relaxation after the manual exercise. Coefficients of variation were computed to identify the measurement condition that discriminated best between the two groups. RESULTS: The most pronounced differences between patients with whiplash associated disorder Grade II and healthy control subjects were found particularly in situations in which the biomechanical load was low. Patients showed higher coactivation levels during physical exercise and a decreased ability to relax muscles after physical exercise. CONCLUSIONS: Patients with whiplash associated disorder Grade II can be distinguished from healthy control subjects according to the presence of cervical muscle dysfunction, as assessed by surface electromyography of the upper trapezius muscles. Particularly the decreased ability to relax the trapezius muscles seems to be a promising feature to identify patients with whiplash associated disorder Grade II. Assessment of the muscle (dys)function by surface electromyography offers a refinement of the whiplash associated disorder classification and provides an indication to a suitable therapeutic approach.     

Impact of comorbidities on the measurement of health in patients with ankle osteoarthritis

BACKGROUND: Investigators seeking to understand the impact of musculoskeletal disorders commonly use validated outcome instruments to assess the effect of diseases on physical function and quality of life. However, the influence of concomitant systemic or musculoskeletal comorbidities on these scores has not been widely considered in orthopaedic research. The purpose of this study was to determine how morbidity unrelated to the ankle influences the perception of physical function and pain by patients with ankle osteoarthritis. METHODS: Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, Ankle Osteoarthritis Scale (AOS) pain scale scores, demographic data, and systemic and musculoskeletal comorbidities were determined prospectively for 195 patients with ankle osteoarthritis and ninety-five age and gender-matched controls. The effect of systemic and musculoskeletal comorbidities on each of the scores was determined. RESULTS: On the average, patients with ankle osteoarthritis had a relatively normal MCS score (47 +/- 13 points) and a markedly diminished PCS score (32 +/- 8 points). Both of these scores averaged 50 +/- 9 points in the control group. The AOS pain score averaged 61 +/- 23 points in the group with ankle osteoarthritis, whereas it averaged 10 +/- 15 points in the control group. We found the perception of ankle pain by patients with ankle osteoarthritis to be significantly and linearly associated with the number of other musculoskeletal problems (not related to the foot or ankle). CONCLUSIONS: The degree of physical impairment associated with ankle osteoarthritis, as measured with the SF-36, is equivalent to that reported to be associated with severely disabling medical problems including end-stage kidney disease and congestive heart failure. The perception of ankle health status as measured with a validated, patient-oriented, anatomically specific instrument is influenced by the patients' perception of their overall musculoskeletal comorbidity status. The authors of clinical studies using these instruments should adjust for concomitant musculoskeletal disease.     

Management of nerve compression syndrome in musicians

Nerve compression syndromes are common in the general population, and they are also common in musicians. As many as 30% of musicians who have a recognized musculoskeletal disorder are diagnosed with a nerve compression syndrome. Thus, it is important to consider the diagnosis of nerve compression syndromes in all musicians who present with musculoskeletal complaints. Proper management of these problems is essential if one is to avoid significant morbidity.     

The value of magnetic resonance imaging in the staging of musculoskeletal tumours

In view of the changes that are occurring in the management of musculoskeletal tumours and the importance of precise pre-operative staging, a study to determine the value of magnetic resonance imaging (MRI) as a modality for this purpose was undertaken. Sixty-four patients were examined and 70 MRI examinations were carried out. Fifteen cases were found to be benign and 49 malignant. As a result of the accuracy of these MRI examinations and their remarkable similarity with the pathological specimens, which was shown to be statistically significant (P less than 0,005), we propose a modification to the sequence of the diagnostic staging modalities for musculoskeletal tumours.     

Comparison of the risk of viral infection between the living and nonliving musculoskeletal tissue donors in Australia

Screening of musculoskeletal tissue donors with nucleic acid testing (NAT) for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) has been implemented in the United States and other developed nations. However, in contrast to the donor demographics in the United States, the majority of Australian musculoskeletal tissue donations are primarily from living surgical donors. The objective of our study was to determine and compare the risk of viral infection associated with musculoskeletal tissue donation from living and nonliving donors in Australia. We studied serum samples from 12 415 consecutive musculoskeletal tissue donors between 1993 and 2004. This included 10 937 surgical donations, and 1478 donations obtained from postmortem organ donation patients and cadaveric donors. Current mandatory retesting of surgical donors 6 months postdonation reduces the risk of viral infection by approximately 95% by eliminating almost all donors in the window period. The addition of nucleic acid amplification testing for nonliving donors would similarly reduce the window period, and consequently the residual risk by approximately 50% for hepatitis B virus, 55% for HIV, and 90% for HCV. NAT, using appropriately validated assays for nonliving donors, would reduce the residual risk to levels comparable to that in living donors (where the 95% reduction for quarantining pending the 180‐day re‐test is included).     

Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates

BACKGROUND: Consistent with osteopathic principles and practice, the nation's colleges of osteopathic medicine (COMs) have emphasized the significance of the musculoskeletal system to the practice of medicine. The authors hypothesized that graduating COM students would, therefore, demonstrate superior knowledge and competence in musculoskeletal medicine when compared with graduates of allopathic medical schools. METHODS: The authors asked graduating COM students to complete a standardized and previously validated 25-question basic competency examination on musculoskeletal medicine in short-answer format. Originally developed and validated in the late 1990s, the examination was distributed to allopathic medical residents at the beginning of their residencies. The authors compare their results with those reported by Freedman and Bernstein for allopathic residents. RESULTS: When the minimum passing level as determined by orthopedic program directors was applied to the results of these examinations, 70.4% of graduating COM students (n=54) and 82% of allopathic graduates (n=85) failed to demonstrate basic competency in musculoskeletal medicine. Similarly, the majority of both groups failed to attain the minimum passing level established by the directors of internal medicine programs (graduating COM students, 67%; allopathic graduates, 78%). CONCLUSION: In an examination of competence levels for musculoskeletal medicine, students about to graduate from a COM fared only marginally better than did their allopathic counterparts. To ensure that all graduating COM students have attained a level of basic competence in musculoskeletal medicine, the authors recommend further study as a prelude to evaluation of the didactic and clinical curriculum at all 22 COMs and their branch campuses.     

More evidence of educational inadequacies in musculoskeletal medicine

In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine. How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education? Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course? A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.