- 11 consistent recommendations were identified for MSK pain from high-quality clinical practice guidelines.
- These could be used to improve MSK pain care by assessing care quality, for example, through audit, guide clinical decision making and identify clinician education needs.
MSK Pain and disability
Musculoskeletal (MSK) pain conditions are the largest contributors to disability worldwide, and one of its contributing factors lie in the lack of quality healthcare.
The common methods of care used to treat MSK pain today include:
- General practitioners refer patients for radiography at the first sign of MSK pain despite the poor relations of imaging findings and symptoms
- In the case of knee osteoarthritis, knee arthroscopy rates have increased from 3% to 4% between 2006 and 2010 even though it is not recommended.
- Shoulder subacromial decompression and rotator cuff repair rates have increased substantially despite evidence to show that the surgical outcomes are comparable to exercise-based rehabilitation
In addition to the overuse of imaging and surgery, there is also a lack of education and advice provided to patients.
Why are CPGs crucial but what is the problem with them?
Clinical Practice Guidelines (CPGs) issue recommendations based on a systematic review of evidence to reduce the gap between theory and application. They also weigh the pros and cons of alternative methods of care, providing information that optimises patient care and prevents the waste of healthcare resources.
The purpose of CPGs are to improve treatment in ways such as:
- Assisting in clinical and patient decision-making,
- Serving as a standard of care,
- Contributing to the creation of tools for clinical decision-making,
- Educating all parties involved on what constitutes best practices, and
- Directing healthcare resources
We’ve been given ready access to many platforms that aim to share with us the best way to give care. However, they aren’t necessarily the easiest to navigate. Some guidelines are too lengthy and difficult to read while some lack transparency in their development. Specifically for guidelines on Musculoskeletal (MSK) pain, many are of lower quality, inconsistent terminology, and lack a balance of representation among different conditions.
What are the 11 recommendations across MSK conditions?
Based on 44 CPGs for Lower Back Pain (LBP), Osteoarthritis (OA), shoulder, and neck conditions, published within 5 years of of the original search date of this systematic review, these 11 consistent recommendations were identified:
|Care should be patient-centred|
This includes providing care that takes into account the unique circumstances of each patient, using effective communication techniques, and applying shared decision-making procedures.
Practitioners should screen patients to identify those with a high likelihood of serious pathology/red flag conditions
These should be identified during an initial assessment which includes:
– Suspicion of infection
– Inflammatory causes of pain
– Severe and progressive neurological deficit
– Serious conditions masked as MSK pain
Psychosocial factors should be assessed
2 LBP CPGs suggested the use of STarT Back or Orebro Musculoskeletal Screening tools to identify psychosocial prognostic risk factors that will later lead to matching care to the level of the patient’s risk. These factors include:
– Yellow flags
– Mood/ emotions
– Fear/ kinesiophobia
– Recovery expectations
Radiological imaging is discouraged unless:
– Serious pathology is suspected
– There has been unsatisfactory response to conservative care or unexplained progression of signs and symptoms
– Imaging is likely to change management
Assessment should include physical examination. Physical examination could include neurological screening tests, mobility and/or muscle strength
Physical assessments include:
– Mobility/ movement
In the case of CPGs for spinal pain, neurological function is recommended to assist in the differential diagnosis of MSK pain disorders
Patient progress should be evaluated, including the use of validated outcome measures
Recommended outcome measures include:
– Seven-point patient self-rated recovery question
– Pain intensity
– Functional capacity/ activities of daily living
– Quality of life
All patients should be provided with education/ information about their condition and management options
– Encourages self-management
– Informs/ reassures patients about their condition or management in terms of prognosis and psychosocial aspects
– Should be individualised based on patient need
Patients should receive management that addresses physical activity and/or exercise
– CPGs among OA, LBP, and neck pain recommended physical activities such as aerobic exercises, or maintenance of of activity
– CPGs for OA had strong recommendations for:
– Strengthening exercises
– Mobility exercises
– Water-based exercises
– Neuromuscular education
– Tai chi
– One CPG for rotator cuff disorder recommended stretching, flexibility, and strengthening as the initial treatment
– Three CPGs for LBP recommended supervised exercise
– CPGs for Neck pain and Associated Disorders (NAD) recommended supervised graded neck strengthening for NAD grade III and as part of multimodal care for NAD grades I-II
If used, manual therapy should be applied only in conjunction with other treatments
Recommended as a component of multimodal care, it should be used together with other management strategies such as exercise, psychological therapy, information/ education, and activity advice instead of a stand-alone treatment
Unless specifically contraindicated (eg, ‘red flag’ condition[s]), offer evidence-informed non-surgical care prior to surgery
Facilitate continuation or resumption of work
What are the consistent recommendations within single MSK pain conditions?
Among conditions for OA, LBP, and neck pain, these were the consistent recommendations found among 12 CPGs (4 for OA, 7 for LBP, and 1 for NAD)
– Offer self-management programmes
– Provide interventions targeting weight loss to people with OA who are overweight or obese
– Do not use glucosamine or chondroitin for disease modification
– Do not undertake knee arthroscopic lavage and debridement unless there is a rationale (such as mechanical knee locking)
Low Back Pain
– Do not offer paracetamol as a single medication
– Do not offer opioids for chronic LBP
– Do not offer selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants or anticonvulsants for LBP
– Do not offer rocker shoes or foot orthotic
– Do not offer disc replacement
– Only offer spinal fusion if part of a randomised controlled trial
– Spinal injections (eg. facet joint injections, medical branch blocks, intradiscal injections, prolotherapy, and trigger point injections) should not be used for LBP
Neck pain disorders should be classified as grades I-IV
How should we, as clinicians, use this information presented to us?
The 11 recommendations give us a clear consensus of the priorities that are essential in treating current MSK pain conditions. The recommendations can guide consumers in making informed decisions about healthcare or assist them in identifying when they receive suboptimal care. It can also guide clinicians in care decision making, assess their practice, and keep a look out for areas that require more learning and development.
The use of these recommendations can also provide health services with the means to assess quality of care during clinical audits by setting the minimum standard. Moving forward, these recommendations could be updated into a set of quality indicators used to set the benchmark of quality healthcare.
Lin I, Wiles L, Waller R, et al. Br J Sports Med 2020;54:79–86. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review