Chapter 12: Musculoskeletal System

Background

Musculoskeletal diseases, from injuries to chronic pain to arthritis, lead to decreased functionality and debility for many patients (Bond et al., 2022). For example, low back pain is the number one condition that creates physical disability around the world (Bond et al., 2022). People of all races and ethnicities experience most musculoskeletal diseases at roughly the same rate, depending on the disorder (Bond et al., 2022). However, racialized groups like Black, Indigenous, Brown, Asian, and Pacific Islander people have far more burden, disability, and worse outcomes than White people with the same conditions (Bond et al., 2022; Thompson et al., 2019).

The research by Bond et al., (2022) states that racialized patients have a higher chance of experiencing negative results such as:

• major lower extremity (leg) amputation;
• subpar anesthesia and analgesia being provided during total joint replacement surgeries;
• fewer patients with rheumatoid arthritis getting the prescriptions they need for anti-rheumatic drugs; and
• fewer patients being properly diagnosed with spinal disc injury and having the surgery they need.

Social Determinant Considerations and Culturally Responsive Practice Points for Health Care Providers:

Health inequities that racialized groups of people experience are due to the social determinants of health and the power structures in our society (Umaefulam et al., 2021). For example, the health of Indigenous peoples in Canada is still greatly affected by colonization (Umaefulam et al., 2021). As Umaefulam et al. (2021) have noted, “Health care providers either consciously (through disregard for cultural values) or unconsciously (by failing to provide culturally relevant care) disempower patients” (p. 194). Indigenous patients report unsafe situations in health care, experiences of racism, and not being understood by health care professionals (O’Brien et al., 2021). This impacts if and how patients access health care. It also decreases the continuity of care and discourages patients’ well-being and ability to manage their diseases (Ulaefulam et al., 2021).

Thompson et al. (2019) have argued that “[s]ocioeconomic status (SES) is a multifactorial construct encompassing knowledge, prestige, power, wealth, social connectedness, and various other resources available to an individual” (pp. 1140–1141). More research needs to be done on how race and SES intersect to decrease MSK health outcomes (Vaughn et al., 2019).

Physical Assessments

Pain is a very common symptom of musculoskeletal diseases. Because of their prior experiences of racial discrimination in health care, many racialized patients do not try to access care for their pain. They try to “tough it out” instead (Bond et al., 2022). For these reasons, it is especially important that nurses provide culturally responsive care to racialized patients and appropriately assess pain [link to pain assessment chapter] as part of a musculoskeletal assessment.

Most parts of the physical musculoskeletal assessment are the same for patients with dark skin as they are for patients with light skin. The main differences are the changes in skin color that may accompany musculoskeletal injury or inflammation. In dark-skinned patients, erythema may be difficult to see, but may show up looking purple (Jarvis, 2019). Palpation will be very important in these situations, since erythematous areas may also feel warm to touch with hardened tissues underneath and taut, shiny skin (Jarvis, 2019). Bruising from musculoskeletal injury will appear deep, dark purple, and will not blanch (Jarvis, 2019).

Osteoarthritis (OA)

• Lower socioeconomic status is a predictor of increased OA risk and poor OA outcomes, including higher levels of pain and disability (Vaughn et al., 2019). This is due to factors such as limited access to medical care, higher environmental and psychosocial stress, food insecurity, and limited access to exercise facilities faced by people with low socioeconomic status (Vaughn et al., 2019). Socioeconomic status is also predictive of outcomes after total joint replacement surgery, the cause of which is frequently OA. Patients with high socioeconomic have lower pain, higher functionality, greater likelihood of receiving total joint replacement, and better postoperative outcomes than patients with low socioeconomic status (Thompson et al., 2019).
• Race and socioeconomic status are closely tied through intersectionality when it comes to OA. Racialized people living in poverty experience more pain and disability due to OA than either racialized people with higher socioeconomic status or White people living in poverty (Callahan et al, 2021; Thompson et al., 2019; Vaughn et al., 2019). These groups of OA sufferers do not have significant differences in the OA severity found in their knees, but experience different pain and functionality as a result of oppression and lack of social power (Callahan et al., 2021; Thompson et al., 2019).
• More Black Americans than White Americans have radiographic and symptomatic knee OA (Vaughn et al., 2019). Black patients with OA have a disproportionate burden of knee OA-related pain symptoms and poor physical function compared to White patients (Thompson et al., 2019; Callahan et al., 2021; Vaughn et al., 2019). Black patients are also less likely to get joint replacement surgery or analgesics for their OA (Vaughn et al., 2019; Kowitt et al., 2019). There are racial differences in the OA disease process. Black Americans “have more severe tibiofemoral OA, tricompartmental OA, and lateral joint space narrowing, and well as a higher prevalence and severity of osteophytes and higher frequency of sclerosis than [White people]. . . . [They are] more likely to have a valgus thrust during walking, which could increase the risk of lateral knee OA and [are] more likely to have joint space narrowing, osteophytes, and cysts compared with [White people]” (Vaughn et al., 2019, p. 636).
• According to Umaefulam et al. (2021), “[Indigenous peoples] have increased prevalence, severity, and undertreatment of arthritis” (p. 194). Indigenous patients with OA also have a greater burden of the disease, including pain, stiffness, and impaired mobility (O’Brien et al., 2020; O’Brien et al., 2021). Access to care for OA is substantially lower for Indigenous people than non-Indigenous people (O’Brien et al., 2021). Indigenous people in Canada consult orthopedic specialist services and have total joint replacements at substantially lower rates than non-Indigenous people (O’Brien et al., 2020). A study by Bond et al. (2022) found that Indigenous people with OA were less likely to seek medical care for their arthritis because they thought they would be racially discriminated against. Indigenous peoples have faced significant increases in chronic conditions like OA, a disadvantage that is caused by the legacy of colonization and marginalization of Indigenous peoples in Canada (O’Brien et al., 2020).
• Psychosocial stress has a negative effect on patient outcomes for OA. The psychosocial stress caused by living in poverty is significant, and poverty experienced by marginalized people tends to be worse than by white people (intersectionality). Thompson et al. (2019) found that “[c]ompared to [White] adults, [Black] adults receive less income at the same education levels, have markedly less wealth at equivalent income levels, and have less purchasing power due to the higher costs of goods and services in the residential environments where they are disproportionately located … When [Black] and [White] adults climb the socioeconomic ladder, discriminatory organizational structures often prevent [Black] adults from making similar gains to [White] adults despite comparable effort” (p. 1140).
• Something that does help racialized people access and navigate the health care system to treat their OA is having health care providers who support them, educate them, and advocate for them (Umaefulam et al., 2021).

Osteoporosis (OP) and Hip Fracture

• Osteoporosis is highly underdiagnosed and untreated in racialized women (Ruiz-Esteves et al., 2021).
• Black women are much less likely to be referred for a bone mineral density test, be screened for OP, or be prescribed medications to manage osteoporosis than White women (Benes et al., 2022; Ruiz-Esteves et al., 2021). Black women with more risk factors such as advanced age, lower health literacy levels regarding OP, lower socioeconomic status, history of smoking or alcohol use are screened for OP even less (Benes et al., 2022). Even when Black women are diagnosed with OP, they are less likely to be treated for the disease compared to White women (Wright et al., 2019).
• Indigenous peoples in Canada have a higher incidence of hip fracture than non-Indigenous Canadians (Brennan-Olsen et al., 2017). Specifically, Indigenous people are 200%–300% more likely to experience a fracture due to OP (Brennan-Olsen et al., 2017). In the US, Indigenous people have the highest incidence of hip fracture compared to all other racial groups (Amir et al, 2019). Determinants such as low socioeconomic status, substance use, comorbidities, fall history, and geographic location are risk factors for OP fracture, while current hormone treatments are protective against OP fractures (Brennan-Olsen et al., 2017; Amir et al., 2019).
• Physiological stress response is often activated by social discrimination such as racism. What follows is dysregulated release of hormones like cortisol that promotes bone remodelling and decreases bone mineral density (Follis et al., 2021). Social strain, including negative social interactions and relationships, is associated with increased risk of hip fractures, especially for Indigenous and Latinx women (Follis et al., 2021).
• Fractures due to OP cause disability and mortality, which disproportionately affect Black and Latinx women in the US (Follis et al., 2021). After fracturing a hip, Black patients are significantly more likely to receive a non-surgical intervention than White patients. Non-surgical treatment of hip fracture generally leads to pain, decreased function, and increased immobility (Amen et al., 2022; Rudasill et al., 2019). Black, Latinx, and AAPI patients wait longer for surgery to treat their hip fractures compared to White patients (Amen et al., 2019). When Black patients do receive hip surgery, they have increased rates of postoperative complications and longer hospital stays (Amen et al., 2022; Lee et al., 2022; Naver et al., 2020). Overall, mortality 1 year following hip fracture is higher among Black patients than White patients (Amen et al., 2022; Lee et al., 2022; Naver et al., 2020; Rudasill et al., 2019).
• Rudasill et al. (2019) noted, “Among all [racialized] patients, research has shown less preventative screening and treatment of OP, increased delays to surgical care, and increased difficulty accessing postoperative care, readmission risk, and overall mortality” (p. 4).
• To mitigate OP racial health inequities, health care professionals must address their biases, develop culturally safe, trusting relationships with patients, and provide much better screening and education around OP causes and treatments (Amen et al., 2022; Wright et al., 2019).
• In their study, Lee at al. stated, “[B]roader social determinants at the community level, such as education, poverty reduction, social and welfare services, affordable housing, job creation, labor market opportunities, and transportation may reduce differences in mortality from hip fractures” (549).

Back Injuries

• One American study found much higher incidence of low back pain among older Black and Latina adults than among older White adults in an underserved community (Bazargan et al., 2021).
• For racialized older adults (compared to White older adults), low back pain is a higher risk factor for emergency department use, dissatisfaction with medical care, depression, decreased quality of life, sleep disorders, and falls (Bazargan et al., 2021).
• Research has shown that nurses, physicians, and other health care professionals believe that Black patients experience less severe pain than White patients, and treat them with less empathy and fewer analgesics accordingly (Licciardone et al., 2022).
• When presenting to emergency departments for low back pain, racialized patients were less likely to receive analgesia and more likely to have long wait times for opiates compared to White patients (Bazargan et al., 2021). Racialized patients were also less likely to receive advanced imaging tests to help diagnose their low back pain in emergency departments (Bazargan et al., 2021).
• Data on chronic low back pain and its prevalence, effects, and outcomes in Indigenous peoples in Canada is insufficient. More research is needed (Health Canada, 2020).
• Treatment of low back pain in racialized people should be approached with equity-oriented responses since it is a social justice issue (Bazargan et al., 2021). According to Bazargan et al. (2021), “Improving access and satisfaction with medical care among [racialized] older adults with pain is the first step toward mitigating some of the racial/ethnic disparities observed” (p. 10).

References

Amen, T., Varady, N., Shannon, E., Chopra, A., Rajaee, S., & Chen, A. (2022). Racial and ethnic disparities in hip fracture surgery care in the United States from 2006 to 2015: A nationwide trends study. Journal of the American Academy of Orthopaedic Surgeons, 30(2), 182–190. DOI: 10.5435/JAAOS-D-21-00137

Bazargan, M., Loeza, M., Ekwegh, T., Adinkrah, E. K., Kibe, L. W., Cobb, S., Assari, S., & Bazargan-Hejazi, S. (2021). Mutli-dimensional impact of chronic low back pain among underserved African American and Latino older adults. International Journal of Environmental Research and Public Health, 18(14), 7246. https://doi.org/10.3390/ijerph18147246

Benes, G., David, J., Synowicz, M., Betech, A., Dasa, V., Krause, P. C., Jones, D., Hall, L., Leslie, L., & Chapple, A. G. (2022). Race and age impact osteoporosis screening rates in women prior to hip fracture. Archives of Osteoporosis, 17(34), 1–8. https://doi.org/10.1007/s11657-022-01076-y

Bond, J., Julion, W. A., & Reed, M., (2022). Racial discrimination and race-based biases on orthopedic-related outcomes. Orthopaedic Nursing, 41(2), 103–115. DOI: 10.1097/NOR.0000000000000830

Brennan-Olsen, S. L., Vogrin, S., Leslie, W. D., Kinsella, R., Toombs, M., Duque, G., Hosking, S. M., Holloway, K. L., Doolan, B. J., Williams, L. J., Page, R. S., Pasco, J. A., & Quirk, S. E. (2017). Fractures in Indigenous compared to non-Indigenous populations: A systematic review of rates and aetiology. Bone Reports, 6(2017), 145–158. http://dx.doi.org/10.1016/j.bonr.2017.04.003

Callahan, L. F., Cleveland, R. J., Allen, K. D, & Golightly, Y. (2021). Racial/ethnic, socioeconomic, and geographic disparities in the epidemiology of knee and hip osteoarthritis. Rheumatic Disease Clinics of North America Journal, 47(1), 1–20. https://doi.org/10.1016/j.rdc.2020.09.001

Follis, S., Klimendtidis, Y. C., Bea, J., Hu, C., Garcia, D., Wactaski-Wende, J., Kohler, L., Shadyab, A. H., Flores, M., Tindle, H. A., & Chen, Z. (2021). The intersectional role of social stress in fracture risk: Results from the Women’s Health Initiative. Journal of Epidemiol Community Health, 75, 1208–1214. DOI: 10.1136/jech-2020-216354

Health Canada. (2020). Working together to better understand, prevent, and manage chronic pain: What we heard. https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2020-rapport/report-2020.pdf

Jarvis, C., Thomas, P., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2019). Physical examination and health assessment (3rd Canadian ed.). Elsevier.

Kowitt, S. D., Aiello, A. E., Callahan, L. F., Fisher, E. B., Gottfredson, N. C., Jordan, J. M., & Meussig, K. E. (2019). How are neighborhood characteristics associated with mental and physical functioning among older adults with radiographic knee osteoarthritis? American College of Rheumatology, 73(3), 308–317. DOI: 10.1002/acr.24125

Lee, C., Schildwachter McConnell, E., Wei, S., Xue, T. Tsumura, Hl, & Pan, W. (2022). Effect of race/ethnicity, insurance status, and area deprivation on hip fracture and outcomes among older adults in the United States. Clinical Nursing Research, 31(3), 541–552. DOI: 10.1177/10547738211061216

Licciardone, J. C., Ganta, W., Geohring, L., Wallace, K., & Pu, R. (2022). Analysis of the patient-physician relationship, race, and pain control and physical function among adults with chronic low back pain. JAMA Network Open, 5(6), 1–11. Doi: 10.1001/jamanetworkopen.2022.16270

Morin, S. N., Berger, C., Liu, W., Prior, J. C., Cheung, A. M., Hanley, D. A., Boyd, S. K., Wong, A. K. O., Papaioannou, A. Rahme, E., & Goltzman, D. (2020). Differences in fracture prevalence and in bone mineral density between Chinese and White Canadians: The Canadian Multicentre Osteoporosis Study (CaMos). Archives of Osteoporosis, 15147), 1–14. https://doi.org/10.1007/s11657-020-00822-4

Nayer, S., Marrache, M., Ali, I., Bressner, J., Raad, M., Shafiq, B., & Srikumaran, U. (2020). Clinics in Orthopedic Surgery, 12(4), 430–434. DOI 10.4055/cios20019

O’Brien, P., Bunzli, S., Lin, I., Gunatillake, T., Bessarab, D., Coffin, J., Garvey, G., Dowsey, M., & Choong, P. (2020). Tackling the burden of osteoarthritis as a health care opportunity in Indigenous communities – a call to action. Journal of Clinical Medicine, 9(8), 2393. DOI: 10.3390/jcm9082393

O’Brien, P., Conley, B., Bunzli, S., Bullen, J., Coffin, J., Persaud, J., Gunatillake, T., Dowsey, M. M., Choong, P. T., & Lin, I. (2021). Staying moving, staying strong: Protocol for developing culturally appropriate information for Aboriginal people with osteoarthritis, rheumatoid arthritis, lupus and gout. PLoS ONE 16(12), 1–13. https://doi.org/10.1371/journal.pone.0261670

Rudasill, S. R., Dattilo, J. R., Liu, J., & Kamath, A. F. (2019). Hemiarthroplasty or total hip arthroplasty: Is there a racial bias in treatment selection for femoral neck fractures? Geriatric Orthopaedic Surgery & Surgery, 10, 2151459319841741. DOI: 10.1177/2151459319841741

Ruiz-Esteves, K., Teysir, J., Schatoff, D., & Yu, E. (2021). Disparities in osteoporosis care among postmenopausal women in the United States. Maturitas, 156, 25–29. DOI: 10.1016/j.maturitas.2021.10.010

Umaefulam, V., Loyola-Sanchez, A., Bear Chief, V., Rame, A., Crane, L., Dleissen, T., Crowshe, L., White, T., Lacaille, D., & Barnabe, C. (2021). Arthritis liaison: A First Nations community-based patient care facilitator. Health Promotion and Chronic Disease Prevention in Canada, 41(6), 194–198. https://doi.org/10.24095/hpcdp.41.6.04

Vaughn, I. A., Terry, E. L., Bartley, E. J., Schaefer, N., & Fillingim, R. B. (2019). Racial-ethnic differences in osteoarthritis pain and disability: A meta-analysis. The Journal of Pain, 20(6), 629–644. https://doi.org/10.1016/j.pain.2018.11.012

Wright, N., Melton, M., Sohail, M., Herbey, I., Davies, S., Levitan, E., Saag, K., & Ivankova, N. (2019). Race plays a role in the knowledge, attitudes, and beliefs with osteoporosis. Journal of Race and Ethnic Health Disparities, 6(4), 707–718. DOI: 10.1007/s40615-019-00569-w