What Does Best Practice Care for Musculoskeletal Pain Look Like?

Musculoskeletal pain is one of the biggest single contributors to disability worldwide and sadly, an emerging cause of this is poor quality healthcare. Common examples of this are; overuse of imaging in low back pain leading to over medicalisation, inappropriate use of surgery against evidence (an example being knee arthroscopy for OA), and the hot topic worldwide at the moment – over reliance on opiates.

For each of these there exists substantial evidence against their use however due to evidence-to-practice gaps they are all still in the mainstream. To overcome the gap between evidence and clinical practice ‘clinical practice guidelines’ or CPGs were introduced with the aim to standardise care and improve outcomes. According to the Institue of Medicine CGPs are:

“…statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”

In essence they are summaries of systematic reviews which aim to clarify how we can get our patients better quickly.

Adherence to CPGs results in better care at lower costs however they aren’t the easiest to access and there has been concern over their transparency and conflicts of interest from authors. Therefore something which was created to clarify best practice for clinicians has ended up muddying the waters.

Thankfully the research team from this featured high-quality systematic review paper has set out to identify  commonalities between MSK pain CPGs for 3 common areas of MSK pain; the spinal, Hip/Knee and Shoulder. In total 44 CPGs were used to create the recommendations; 15 for LBP, 14 for OA, 6 for the shoulder and 5 for the neck. Each CPG was evaluated.

What Best Care Looks Like – The 11 Recommendations

  1. Care should be patient centered and individualised
  2. Patients should be screened for red flags
  3. Psychological factors should considered for all
  4. Radiological imaging should be discouraged unless serious pathology is suspects, there has been unstatisfactory response to conservative care or it is likely to change management
  5. Physical examination should always be performed and should contain neurological screening tests
  6. Outcome measure should be essential
  7. Education should be a central focus of treatments with all treatment options explained
  8. Physical activity and exercise should be part of treatment plans
  9. Manual therapy as an adjunct only to other evidence based treatments
  10. Return to work ASAP
  11. Conservative treatment prior to surgery in all but specific cases

For each of the 3 areas there are recommendations specific to conditions. For OA self management programmes should be offered, weightloss should be targeted, glucosaime or chondroitin should be avoided and arthroscopy should be used in mechanical locking only.

For LBP paracetamol as a single medicine is ineffective and opioids, SSRIs, SNRIs, TCAs  or anticonvulsants should not be used for chronic back pain. Rocker shoes or insoles should be avoided and spinal injections should not be used for LBP.

The only specific recommendation for neck pain is that disorders should be classified from I-IV.

Clinical Implications

When reading these recommendations there is likely to be an emotional response which is going to be hard to overcome. It is important to slow down, consider the evidence, think that they have been made for a reason. There is likely to be some aspects of all of our clinical practice which needs to change or adapt to give the best outcomes for our patients at the best value.

If you would like to read evidence around the recommendations you should check out our awesome Physiopedia pages whcih are linked to down below.