1. By Hatim Jaber MD MPH JBCM PhD 17-10-2018
Faculty of Medicine Musculoskeletal Systems and Skin Epidemiology of MSS diseases and injuries. Osteoporosis : risk factors and prevention By
Hatim Jaber
MD MPH JBCM PhD

5. Objectives Define: Epidemiology of MSS diseases and injuries.
Distinguish between harm, risk and hazard.
Identify the human, situational and environmental risk factors of accidents and Injuries.
Explain the factors that influence Osteoporosis and its prevention.

6. Presentation outline Epidemiology of MSS diseases and injuries.
Time
Epidemiology of MSS diseases and injuries.
11:00 to 11:10
Harm, risk and hazard.
11:10 to 11:20
Risk factors of accidents and Injuries.
11:20 to 11:35
Osteoporosis and its prevention.
11:35 to 11:50

7. Classifying deaths and diseases (WHO)
Communicable diseases [Group I]
Those where death is directly due to the action of a communicable agent
Non-communicable diseases
Diseases [Group II]
Cancer, diseases of various organ systems (eg respiratory, cardiovascular etc.), diabetes, mental health etc.
External causes (injuries, poisonings and violence) [Group III]

8. Distribution of global injury mortality by cause
Other unintentional injuries %
Suicide %
Road traffic injuries account for 23% of all injury deaths worldwide
Drowning 7.3%
Violence
10.8%
Fires 6.2%
War 3.4%
Other intentional injuries 0.2%
Falls 7.5%
Poisoning 6.7%
Road traffic injuries %
Source: WHO Global Burden of Disease project, 2002, Version 1
23│ © WHO, 2007

9. Diseases of the Musculoskeletal System

10. Skeletal Skeletal trauma/fractures Incidence
Young males and older adults
Tibia, clavicle, lower humerus (young persons)
Hands, feet -- workplace accidents
Upper femur, upper humerus, vertebrae, pelvis (elderly)
Osteoporosis
Diff. types (complete/incomplete, open/closed)
Incomplete -- bones of children
Flexible
Growing
Stress w/ repeated stress (ex athletics)
Fatigue
Insufficiency (weight bearing bones)

11. Metabolic bone disease (Osteoporosis)
remodeling imbalance favors bone resorption
Incidence
Common disorder of bone metabolism
Heredity evidence in women
Fracture due to bone weakness
Common -- vertebrae, distal radius, proximal femur
Fractures after trauma
Compression fractures (esp. vertebral)
Non-symptomatic until indicated by fracture

12. Bone tumors Common secondary tumor site
Primary often prostate, breast, thyroid, lung, kidney
Access through blood
Often axial skeleton (not skull), proximal femur, humerus
May induce bone breakdown or bone growth

13. Diseases of the Joints Osteoarthritis = Degenerative Joint Disease
Incidence
Most common joint disease
Incr=s w/ age
Age most affected
> 75 yrs % affected
Pathophysiology
Articular cartilage becomes thin, irregular, frayed
Probably enz breakdown of cartilage
 Cracks, fissures in articular cartilage
Fill w/ synovial fluid

14. Rheumatoid arthritis - systemic disease involving joints
Incidence
About 1% adult pop=n affected
3 female: 1 male
Age of onset usually (but also infancy  90's)
May be due to
Infection
Autoimmune disorder
Genetic predisposition

15. Diseases of Skeletal Muscle
Disuse atrophy
Pathologic reduction in size of muscle fibers
Follows prolonged bed rest, trauma, nerve damage
Muscle strength decreases from baseline
About 3% per day
To prevent
Frequent isometric muscle contractions
Passive lengthening exercise
If no reuse in 1 year, regen=n muscle fibers impaired

16. Fibromyalgia Chronic musculoskeletal syndrome
Get diffuse chronic pain, tenderness w/ no inflammation, fatigue
9 common points in body (neck, shoulders, hips, knees)
Profound fatigue
May  depression
Also migraine, irritable bowel disease common
Incidence
Mostly women
Peak age = yrs
Increases w/ age

17. Muscle Strains Gen’l term for muscle damage
Seen after traumatic, sports injuries
Sudden, forced motion
Muscle becomes stretched beyond normal length
May include wounds
Often involves tendon also
May include hemorrhage, inflammation
Muscle cells usually regenerate in up to 6 weeks
Treatment
Ice relieves swelling
Analgesics
Alternating heat/cold if more severe form
Surgery, immobilization if tearing, bleeding

18. Musculoskeletal Disorders
May accompany fractures, dislocations
Ligament = fibrous connective tissue band joining bones and joint
Needed to support bones, joints
Strain = tear in tendon
May be due to major trauma
Also spontaneous w/ corticosteroid admin, rheumatoid arthritis, lupus

19. Musculoskeletal Diseases and Demographic Characteristics
Low Back and Neck Pain
Spinal Deformity
Arthritis and Related Conditions
Osteoporosis and Bone Health
Injuries – Traumatic, Workplace, Sports, Military
Children and Adolescents
Tumors of Bones and Joints, Muscles and Tissues
Rare Bone Diseases
Neuromuscular Disorders
Diseases of the Muscles
Aging
Sex and Gender

20. Impact of Musculoskeletal Diseases on
The Big Picture
Impact of Musculoskeletal Diseases on
Individuals
The Health Care System
The Economy

21. Prevalence of Musculoskeletal Diseases
1 in 2 adults are affected, twice the rate of chronic heart and lung conditions
Source: National Center for Health Statistics, National Health Interview Survey, 2012

22. 1 in 2 women and 1 in 4 men over age 50 will have an osteoporosis-related fracture, with 20% mortality rate within 12 months of a hip fracture
[1] Includes hospital discharges, ED, outpatient, and physician visits.
[2] Includes only hospital discharges and ED visits.
Source: National Center for Health Statistics, NHDS, NAMCS, 2010.
Millions more suffer from spinal deformities, congenital conditions, cancers of bone and connective tissue, and rare musculoskeletal diseases

23. Health Care Visits for Musculoskeletal Diseases
18% of all health care visits in 2010/2011 had a musculoskeletal condition diagnosis listed
29% of hospital discharges
16% of physician visits
14% of outpatient visits
29% of emergency department visits
File: G1E.0.1.png

24. Chronic Pain of Musculoskeletal Diseases
1 in 4 persons over age of 18 report chronic joint pain in at least one joint
Knee is the most frequent site (17%)
Shoulder is 2nd most frequent site (8%)
Hip is 3rd most frequent site (6%)
40% = percentage of persons over age 65 with chronic joint pain

25. due to Musculoskeletal Diseases
Limitations
due to Musculoskeletal Diseases
6% of population reports limitations carrying out common activities of daily living (eating, dressing, bathing) due to musculoskeletal diseases
14% ages report limitations due to musculoskeletal condition
23% age 75 and older

26. Bed Days due to Musculoskeletal Diseases
A bed day is ½ or more days in bed due to injury or illness in a 12 month period, excluding hospitalization
72% of them had a bed day due to musculoskeletal condition – 1 in 4 adults

27. Lost Work Days from Musculoskeletal Diseases
A lost work day is absence from work due to illness or injury in 12 month period, excluding maternity or family leave
1 in 6 persons age 18 and over report at least one lost work day for medical reasons
74% of them cite a lost work day due to a musculoskeletal condition – 1 in 8 persons in the work force

28. Burden of Musculoskeletal Diseases
Widespread prevalence
Three of the most costly healthcare conditions
Trauma
Back pain
Arthritis
Low mortality from musculoskeletal diseases, but high morbidity
Restrict activities of daily living
Cause lost work days
Source of lifelong pain

29. Definitions of Cost
Direct Costs = Health care costs for treatment of disease.
Indirect Costs = Impact of disease in terms of lost wages due to disability or death.
Aggregate Total Costs = Total medical costs for musculoskeletal diseases and other comorbid conditions of persons with musculoskeletal conditions.
Incremental Costs = Share of costs directly attributable to musculoskeletal disease.

30. Key Challenges to Future
Medical costs rapidly increasing for persons age 45 to 64.
Total medical costs rose 40% between and
Incremental costs attributed to musculoskeletal diseases rose 67% between and
Persistence of chronic musculoskeletal diseases that begin in middle years 45 to 64 throughout lifetime.
Aging population.
Lack of research funding for treatment and prevention of painful and debilitating musculoskeletal diseases.

31. Hazard is something with the potential to cause harm, such as a substance, a piece of equipment, a form of energy, a way of working or a feature of the environment.
Harm includes death and major injury and any form of physical or mental ill health.
Risk it is a measure of the probability that the hazard (defined previously) will manifest some degree of harm.

32. Accidents
Sudden unfavorable event following series of consequent and /or parallel human errors.
Accidents are the end-products of unsafe acts and unsafe conditions of work.
Factors- technical equipment
working environment
worker
Accidents have preventable causes

33. Factors that cause or contribute to accidents
The systems approach- accidents occur because of the interaction between system components
Direct causal factors in safety
the employee performing a task
the task itself
any equipment directly or indirectly used in the task
other factors - social/psychological & environmental

34. Injury Causation Model
Microorganism
Energy
Environment
Environment
Vector
Vector or
Vehicle
Host
Host
Infectious disease model
Injury model

35. Injury Prevention and Control: “Accidents” and “Safety”
The term accident has fallen into disfavor and disuse with many public health officials
Accident suggests a chance occurrence or an unpreventable mishap
Many, if not most, accidents are preventable
The term unintentional injury is now used in its place

36. Unintentional Injuries
Injuries judged to have occurred without anyone intending that harm be done
E.g., injuries resulting from car crashes, falls, drownings and fires
Intentional Injuries
Injuries judged to have been purposely inflicted, either by the self or another person
E.g., assaults, intentional shootings and stabbings, homicides, and suicides

37. Four Characteristics of Unintentional Injuries
They occur following an unplanned event
They are usually preceded by an unsafe act or condition (hazard)
They are often accompanied by economic loss or injury
They interrupt the efficient completion of a task

38. Costs of Unintentional Injuries to Society
Cause of Death Rank (5th)
Ranked 1st in Years of Potential Life Lost Before Age 65 (YPLL65 )

39. Risk Factors for Intentional Injury Child Abuse
Family history of abuse (parent or spouse abuse)
Parental mental illness or substance abuse
Family dysfunction or disruption (absent parent or inadequate parenting skills
Socioeconomic stress (poverty, homelessness)
Child characteristics (overactive, difficult, or disabled)

40. Injury Deaths among Young People
Injuries are an especially important cause of death in young people
injuries caused --
43% of deaths in children aged 1-4
52% of deaths in children aged 5-14
76% of deaths in children aged 15-24

41. Injury Rates: Gender and Socioeconomic Status
[New slide]
Injury Rates: Gender and Socioeconomic Status
Males are more likely to sustain injuries than females, with a fatal injury rate 2.5 times higher than that for females for all age groups combined
Injury rates, like other indicators of poor health, are higher in groups of lower socioeconomic status

42. Injury Rates: Gender and Socioeconomic Status (cont’d.)
[New slide]
Injury Rates: Gender and Socioeconomic Status (cont’d.)
Injury rates, like other indicators of poor health, are higher in groups of lower socioeconomic status
The death rate from unintentional injury is twice as high in low-income areas as in high-income areas
House fires, pedestrian fatalities, and homicides are all more common among the poor
Low-income individuals are more likely to have high-risk jobs, low-quality housing, defective and old cars, and such hazardous products as space heaters -- all of which contribute to higher injury risks

43. Occupational Injuries
Workplace injuries have been a significant public health problem since the Industrial Revolution

44. Most Frequent Causes of Workplace Deaths and Injuries
Injury
Overexertion
Impact accidents
Falls
Bodily reaction to chemicals
Compression
Motor vehicle accidents
Exposure to radiation/caustics
Rubbing or abrasions
Exposure to extreme temperatures
Deaths
Motor-vehicle related
Falls
Electrical current
Drowning
Fire related
Air transport related
Poison
Water transport related
Other

45. Approaches to the Prevention of Intentional Injuries
Education
Opportunities for Recreation and Employment
Regulation and Law Enforcement
Counseling and Treatment

46. Four Broad Strategies for the Prevention of Unintentional Injuries
Injury Prevention Education
The process of changing people’s health-directed behavior in such a way as to prevent unintentional injuries
Regulation
Enactment and enforcement of laws to control conduct as a means of reducing the number and seriousness of unintentional injuries
E.g., speed limits, state laws requiring safety belts and motorcycle helmet use, and child restraints in automobiles
In a “free society,” such as the U.S., there is a limit to how much can be accomplished through legislation
The strategy of prevention through regulation can be difficult to implement -- i.e., the idea of regulating health behavior grates against the individual freedom that Americans have come to expect

47. Four Broad Strategies for the Prevention of Unintentional Injuries (cont’d.)
Automatic Protection
Combining engineered changes with regulatory efforts -- i.e., automatic (or passive) protection
E.g., Child-proof safety caps on aspirin and other medicine containers
E.g., In 1973 free, easily installed window guards began to be provided to New York City families living in high-risk areas; by 1975, a 50% reduction in falls of young children from windows and 35% decrease in deaths from such falls
Litigation
Lawsuits from injured victims or their families have been successful in removing dangerous products from store shelves or otherwise influencing changes in dangerous behavior
E.g., 3rd-party responsibility of bar owners and bartenders for serving alcohol to a drunken customer who later injures another person

48. Osteoporosis Overview

49. Osteoporosis absolute decline in the bone mass (bone atrophy)
Pathogenesis
excessive amount of osteoclastic resorption or impairment of osteoblast-mediated bone formation, or both
Primary osteoporosis:
type I osteoporosis (postmenopausal): ↓oestrogen → ↑bone resorption (↑number and activity of osteoclasts)
type II osteoporosis (senile): individuals older than 70 years
impairment of bone formation (failure to replace resorbed bone)

50. Secondary osteoporosis
Cushing’s syndrome
hyperthyreoidism
hypogonadism (early oophorectomy)
malnutrition
subtotal gastrectomy
immobilisation, hemiplegia, paraplegia
treatment with glucocorticoids or certain anticonvulsants
Clinical features:
fractures as a result of minimal trauma
hip fractures
compressive fractures of the vertebral bodies – kyphosis (“dowager’s hump“)
fractures of the distal radius (Colles’ fracture)

51. defective mineralization of osteoid matrix
Osteomalacia and Rickets (rachitis)
defective mineralization of osteoid matrix
Lack of vitamin D:
low dietary intake
lack of sunlight
small gut malapsorption
chronic liver and/or renal diseases (impaired hydroxylation of vitamin D precursors)
Hypophosphataemia (much less common, resistance to treatment with vitamin D):
hereditary (abnormality of phosphate transport by the renal tubular epithelium)
tumour-associated (effect of certain mesenchymal neoplasms)

54. Injuries represent a large proportion of child deaths, in particular for older children

56. Osteoporosis Overview
Affects 18-28% of women and 6-22% of men over the age of 50 years old
Half of all postmenopausal women and a quarter of men over 50 years old will have an osteoporosis related fracture

57. Osteoporosis
Eight times more common in women than men for several reasons
Lower calcium intake than men
Less bone mass because of smaller frame
Bone resorption begins earlier and accelerates after menopause
Pregnancy and breastfeeding deplete woman’s skeletal reserve of calcium
Longevity increases likelihood of osteoporosis; women live longer than men

58. Risk Factors: non-modifiable
Age (increasing)
Low BMI (small, low weight;< 58 kg)
Ethnicity: Caucasian > Asian/Latino > African American
Family History of Fracture
Rheumatoid Arthritis

59. Risk Factors: Modifiable
Sex Hormones (low estrogen/testosterone)
Oophorectomy
Low calcium and vitamin D
Inactive lifestyle
Excessive alcohol
Cigarette smoking
Hyperparathyroidism (primary or secondary)
Hyperthyroidism
GI conditions which impair adequate nutrition
Steroids or Cushing’s
Proton pump inhibitors

60. Risk Factors for Hip Fracture
Bone Mineral density
Fall on hip
Neuromuscular impairment
Ethnicity (Caucasians)
Age
Multiple falls in last year
BMI (if lower)
Vision impairment
Physical inactivity

61. Risk of fracture in patients with osteoporosis

62. Osteoporosis Diagnostic Studies
Clinical Manifestations
Known as silent disease
Diagnosis
Bone Mineral Density (BMD)
Dual-energy x-ray absorptiometry (DEXA)
History and physical
Quantitative ultrasound

63. X-ray evidence of osteoporosis
May be present and can be clue for further evaluation

64. Screening DEXA scan is the most reliable method
All women 65 years old and older be routinely screened for osteoporosis.
Men > 70
Younger patients (50-64) with equivalent risk of 65 year old woman
Special populations: glucocorticoids, anti-estrogen, anti-testosterone

65. DEXA scan Dual energy x-ray absorptiometry
two photons are emitted from an x-ray tube, gives very precise measurements at clinically important sites with minimal radiation.
Measures bone mineral density, approximation of bone mass and best predictor of fracture risk
Measurement: standard deviation of normal young subjects (T-score) and age-matched (Z-score)

66. DEXA-image

67. Osteoporosis Prevention
Adequate nutrition, particularly calcium and vitamin D
Calcium: 1000 – 1200 mg daily (diet plus supplementation)
Vitamin D: goal level of around (most 1000 units daily)
Weight bearing exercise
Discourage smoking
Discourage alcohol abuse
Reduction of risks for falling: consider OT evaluation for home hazards, minimize sedating medications.
Hip protectors: can be useful if worn properly but often have low compliance.

68. Nutrition and Musculoskeletal Health
Consume fresh and colorful fruits and vegetables: of each/day;
Eat cold water fish (salmon, halibut, scallops,tuna, mackerel,cod, shrimp, snapper, and sardines) ≥ 2x/week;
 intake of anti-inflammatory foods;
Minimize intake of alcohol, caffeine, and processed meats (lunch meats, hot dogs and sausages);
Avoid tobacco products.

69. Summary Musculoskeletal health requires: A balanced training program:
Cardiovascular activity
Agility and balance
Strength (core)
A healthy diet:
Colorful fruits & vegetables
Whole grains
Cold water fish