December 1999 Bulletin

Bone and Joint Decade 2000-2010

Worldwide focus on musculoskeletal disorders, research

By Carolyn Rogers

As the curtain falls on the 20th century, the orthopaedic profession is waiting in the wings, ready to take center stage for the next 10 years. The first decade of the 21st century will be devoted to the understanding and treatment of musculoskeletal disorders. Fifteen countries already have declared 2000-2010 to be the Bone and Joint Decade and Kofi Annan, Secretary General of the United Nations, is expected to give UN support to the decade. Some 50 countries with more than 450 organizations and journals worldwide are laboring on behalf of the Bone and Joint Decade.

The sense of "opening night" excitement is palpable to people like Bruce Browner, MD, a member of the International Bone and Joint Decade Steering Group, and a self-described zealot on the topic.

"Incredible things can be accomplished through this effort-I could talk about this for hours," says Dr. Browner, professor and chairman of the department of orthopaedic surgery at the University of Connecticut, Farmington, Conn. "When you think about it, you see and hear about cancer, heart disease, aids, and stroke all the time. Musculoskeletal problems are the most common cause of severe long-term pain and physical disability-affecting hundreds of millions of people around the world. But I've never seen that level of attention paid to these disorders. Not even close. And I think it's high time these issues had that kind of emphasis."

The seed for the Bone and Joint Decade was planted in mid-1996 when Lars Lidgren, MD, PhD, chairman of the department of orthopaedic surgery at Lund University in Sweden and president of the European Orthopaedic Research Society, inquired about the construction of a large neuroscience center on his campus. He discovered that the $60 million project was a direct result of the Decade of the Brain 1990-2000, a time designated to focus attention on the plight of those with neurological disorders such as stroke or Alzheimer's.

If the concept of a decade could provide this type of added support for neuroscience, he wondered, what could a similar decade do for the musculoskeletal field? After a few private discussions in Sweden, he organized a consensus meeting-with the support of a planning grant from the Swedish Medical Research Council and Lund University-to consider the possibility.

Dr. Browner, chair of the Academy's International Committee, was sent to the April 1998 meeting in Lund, Sweden, along with more than 70 other delegates representing 50 professional and patient organizations related to orthopaedic surgery, rheumatology, osteoporosis, traumatology, physical medicine and rehabilitation, and physical therapy. After considering the magnitude and impact of musculoskeletal problems, the delegates agreed to launch the Bone and Joint Decade, 2000-2010, and Dr. Browner came back to the United States to sell the concept to the Academy board of directors and COMSS. Since that time, Dr. Browner says, he has been gratified to see the support grow from an initial, polite philosophical endorsement to a high level of enthusiasm and activity.

The timing is right for this endeavor for several reasons, Dr. Browner says. "Due to the decrease in infectious diseases and in the birth rate, the world's population is aging, causing musculoskeletal problems to increase in importance. In the next decades, as baby boomers age, there will be a tidal wave of people with osteoporosis, osteoarthritis and other joint diseases. These conditions are already consuming an extensive and growing portion of resources in many countries, and the problems are going to be magnified, so we're going to have to come up with solutions."

Also, a silent epidemic is underway-the increased use of motor vehicles in developing countries has led to an explosion in the number of traffic-related injuries.

"There is virtually no regulation in these countries," he says. "There's very little policing, poor signage, no helmets, and poor drunk driving control. Most of these victims are the vulnerable road users-pedestrians, bicycle riders-and they are much more seriously injured than those protected by a car. Right now, these countries incur more costs related to the medical care and lost productivity associated with road-traffic crashes than they receive in the form of foreign aid and loans. The Global Burden of Disease, a 1996 World Health Organization and World Bank report, predicted that road-traffic injuries will rise from the ninth to the third leading cause of death and disability in the next 20 years. If this trend isn't reversed, 6 million people will die and 60 million will be seriously injured or crippled in the next 10 years."

The International Bone and Joint Decade Steering Group and the Academy are collaborating with the World Bank, which has initiated a project entitled the Global Road Safety Partnership.

"We feel we have a direct interest in participating in this effort," Dr. Browner says. "With minimal or no emergency medical services, many orthopaedists in these countries are very involved in caring for the surviving patients with fractures, paraplegia, etc."

Another significant linkage for the Bone and Joint Decade is with the World Health Organization, which is sponsoring a workshop to be held in Geneva, Switzerland Jan. 14-15, "The Burden of Musculoskeletal Conditions at the Start of the New Millennium." They see this effort as an extension of their "The Global Burden of Disease" study.

The primary goals of the Bone and Joint Decade are to:

It is important to note that this decade is meant to be all-inclusive, and "encompasses every musculoskeletal disorder imaginable," Browner says. While President Clinton has yet to endorse the years 2000-2010 as the Bone and Joint Decade in the United States, efforts are continuing on that front. Three U.S. congressmen, Rep. Steny Hoyer (D-Md.), Rep. Sherrod Brown (D-Ohio) and Rep. Frank Pallone (D-N.J.), and former President Gerald Ford have sent letters to President Clinton asking him to issue a proclamation. National sports figures and other celebrities also are being asked to pledge their support, and the Academy has established a toll-free number (888-671-4900) which allows doctors, their patients or associates to fax a message to President Clinton.

Now that Texas and Missouri have endorsed the Bone and Joint Decade, the Academy is encouraging state orthopaedic societies and orthopaedic surgeons in other states to work with their elected officials to issue similar proclamations. The Tennessee Orthopaedic Society, for example, is prepared to introduce a Bone and Joint Decade resolution-modeled after the Texas proclamation-to the state's general assembly when it meets in January. It is hoped that a groundswell of support from the states-as well as other countries, organizations and individuals-will further encourage President Clinton to sign a nationwide proclamation.

With or without this decree, the Bone and Joint Decade effort in the United States is kicking into high gear. Representatives from 18 bone and joint-related organizations assembled in Washington D.C., on Oct. 8, 1999, to establish a plan of action for a National Action Network (NAN) of the Bone and Joint Decade in the United States. Fifty countries have formed NANs to assist individual groups and organizations in planning their Bone and Joint Decade activities.
Armin Kuder, representing the International Steering Committee of the Bone and Joint Decade, left, and Stuart Weinstein, MD, chair Task Force on Bone and Joint Decade, discuss plans for National Action Network.

The NAN in the United States is an umbrella coalition that is open to any organization that endorses the missions and goals of the Bone and Joint Decade.

Lawrence S. Hoffheimer, executive director and founder of the National Foundation for Brain Research and one of the primary forces behind the Decade of the Brain, urged the group at the Oct. 8 meeting to "keep it as open and informal as possible. Don't create a cumbersome bureaucracy, or set up an approval process for activities. Always be mindful that individual organizations have special interests."

"The Decade of the Brain was the impetus for this effort," noted Stuart Weinstein, MD, chair of the Academy Task Force for the Bone and Joint Decade. "They organized themselves extremely well and were able to glean tremendous support from Congress. President Bush signed a proclamation designating the Decade of the Brain."

The neurosciences benefited greatly from the 10-year endeavor, Dr. Weinstein said, citing a recent Science magazine article that concluded that the Decade of the Brain has "strongly enhanced public awareness of the benefits to be derived from brain research."

According to Science, the decade resulted in an extraordinary increase in the visibility of the neurosciences, and provided a forum to publicize brain research. This increased visibility resulted in an additional $15 million in funding for neuroscience research for each year of the decade. Other accomplishments included the annual brain awareness week, which brought the neurosciences down to the community level and into classrooms across the country.

Science also noted increased media attention to breakthroughs in neurosciences, with more than 500 scientific articles published, four Time magazine covers related to the neurosciences, a Sunday supplement in the Washington Post specifically dedicated to the Decade of the Brain, and a "Decade of the Brain" television series on Lifetime Television. Notably, the Society for Neuroscience grew by 1,000 members a year throughout the decade and there was a tremendous growth in the number of scientists identifying themselves as neuroscientists.

Also emerging from the Decade of the Brain are the extraordinary liaisons developed between congressional leaders, the administration, disease advocacy groups, scientists and the National Institutes of Health.

While the Decade of the Brain was clearly a successful effort, Hoffheimer believes that the Bone and Joint Decade holds even more potential.

"More people in America are affected by bone and joint problems than by neurological problems, and considerably more treatments are available for musculoskeletal conditions than for neurological ones," Hoffheimer said.

Dr. Weinstein was enthusiastic about the tone of the October meeting. "Everyone seemed to realize the importance and the benefit of working together to achieve common goals and to accomplish the mission of the Bone and Joint Decade," he said. "Collectively, we can accomplish our own individual goals a lot better than we can as individual organizations."

The official kickoff of the Bone and Joint Decade will take place at a meeting of the World Health Organization on Jan. 13, 2000, in Geneva, Switzerland.

Burden of disease


Joseph Buckwalter, MD, and Leigh Callahan, PhD, Arthritis Foundation, discuss aims of conference on Measuring the Burden of Disease, Musculoskeletal Conditions and Injuries
Critical to the success of the Bone and Joint Decade 2000-2010 is the ability to measure the burden of musculoskeletal disease. To this end, 41 representatives from 36 organizations-including medical specialty societies, professional societies, advocacy groups and government agencies-attended an Academy- sponsored conference in Rosemont, Ill., "Measuring the Burden of Disease, Musculoskeletal Conditions and Injuries," on Oct. 5.

"The cornerstone of the Bone and Joint Decade is identifying the global burden of disease," said Joseph A. Buckwalter, MD, chair of the Academy's Council on Research and Scientific Affairs, in his introduction to the conference. "What is the incidence and prevalence of musculoskeletal conditions? What is the impact on the individual, on family and society? Where do we have knowledge, and more importantly, where don't we have knowledge?"

The purpose of the conference was to discuss various ways to measure of burden of musculoskeletal conditions and injuries, and to produce a preliminary action plan for measuring the burden of musculoskeletal disease in the United States. The groundwork for this national effort lies in the international Bone and Joint Decade Monitor Project, a working group from the International Bone and Joint Decade Steering Committee-in collaboration with the World Health Organization-which is currently reviewing and collating data on the burden of musculoskeletal conditions globally.

Anthony D. Woolf, PhD, chair of the working group for the Bone and Joint Decade Monitor Project, participated in the conference by phone, saying that musculoskeletal conditions worldwide are "underrecognized, underappreciated, and underresourced."

"In the U.S. alone, it's estimated that the cost of musculoskeletal conditions is around $215 billion per year," said Dr. Weinstein. "Musculoskeletal impairments are the number one category of reported chronic impairment and rank number one in visits to physicians' offices. Thirty-six million people now have musculoskeletal impairments that impact on their activities of daily living. And, as our population ages over the next decades, that number is expected to rise accordingly."

In spite of those numbers, it's widely believed that the true burden of musculoskeletal conditions is even greater. But because musculoskeletal conditions generally are not fatal, they receive considerably less attention from lawmakers, the media and the public than heart disease, AIDs, or cancer. One of the goals of the Bone and Joint Decade is to make sure that musculoskeletal research is not ignored; hence the need for more comprehensive data on the true burden of these conditions.

Unfortunately, current measures of the burden of musculoskeletal disease have significant limitations.

"We've found that it's difficult-a tremendous effort-to try to get a comprehensive dataset and to come to some sort of consensus on how to measure the impact and importance of musculoskeletal conditions," Dr. Buckwalter said.

One of the aims of this conference was to build a consensus about how best to measure this burden.

Conference keynote speaker Dorothy Rice, PhD, professor in residence in the department of social and behavioral sciences at the University of California, with joint appointments at the Institute for Health and Aging and the Institute for Health Policy Studies, spoke about the special significance that the measurement of disease, illness and injury takes on in an era of tightening resources for research.

"The setting of priorities for the allocation of these resources, and the evaluation of health services programs and biomedical research can be greatly improved with more complete information on the burden of disease," Dr. Rice said.

Dr. Rice also stressed the need for longitudinal data. "Little information is available on the progression of disease and the impact over time on individuals and families," she said.

The international Bone and Joint Decade Monitor Project will hold its major meeting at the kickoff of the Bone and Joint Decade in Geneva, Switzerland, in January. The group will adopt measures that can that can be used to monitor outcomes over time. In addition, the Bone and Joint Decade Monitor Project will address the present provision of musculoskeletal care, the ideal provision of care, the attendant costs and priorities for change in the care of patients with musculoskeletal conditions.

What can you do to promote the Bone and Joint Decade?

Use the "Bone and Joint Decade" logo on your stationary letterhead.

Present a program tied to the Bone and Joint Decade at your local school or community center, such as "How to Maintain your Musculoskeletal Health."

Use the Bone and Joint Decade PowerPoint slide set to promote the decade-it's available on the U.S. web site, www.bonejointdecade.org. The Academy also has a Bone and Joint Decade slide set and a traveling exhibit that you can use on a loan basis when promoting the decade. Contact Brenda Welborn, program coordinator, (847) 384-4182 or e-mail at welborn@aaos.org.

Hand out Bone and Joint Decade brochures at your office to educate patients about the decade and its importance to their health.

Send a letter to your governor and state legislators informing them of the huge impact of musculoskeletal conditions on society and urge them to join Texas and Missouri in declaring 2000-2010 the Bone and Joint Decade in your state.

Keep up with Bone and Joint Decade activities by accessing the U.S. web site at www.usbjd.org/, or visit the international web site at www.ort.lu.se

What can your state do?

The Academy is encouraging each of the state orthopaedic societies, their key contacts and members to work with their elected officials in passing a proclamation in their state declaring the years 2000-2010 as the Bone and Joint Decade. States differ in the way these declarations can be accomplished-some require that the legislature has to approve the proclamations, while in other cases it may be within the discretion of the governor of the state. Orthopaedic surgeons are urged to contact their governor, their legislators, and mayors asking for their support in this effort.

An information packet has been developed by the Academy to assist orthopaedic surgeons and state orthopaedic societies interested in having 2000- 2010 declared as the Bone and Joint Decade. The packet includes:

To obtain a packet, contact Susan Koshy, AAOS manager, state society and legislative affairs, (847) 384-4314, or email koshy@aaos.org.


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