What does best practice care for musculoskeletal pain look like?

PainSci » bibliography » Lin et al 2019
updated Jul 31, 2024

Tags: treatment, musculoskeletal medicine, what works, best practices, study_review, study_guideline, study_opinion, scientific medicine

Two pages on PainSci cite Lin 2019: 1. What Works for Chronic Pain? 2. Reality versus best practices in musculoskeletal medicine

PainSci commentary on Lin 2019: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This paper distilled several key best practices in musculoskeletal medicine from eleven recent, high quality, English clinical practice guidelines (out of a pool of dozens of candidates). Note that I have translated this list into plain English in What Works for Chronic Pain? (see the section “Actually using best practices in musculoskeletal medicine”). This is quoted from the paper:

Care should be patient centred. This includes care that responds to the individual context of the patient, employees effective communication and uses shared decision-making processes.
Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions.
Assess psychosocial factors.
Radiological imaging is discouraged unless:
1. Serious pathology is suspected.
2. There has been an unsatisfactory response to conservative care or unexplained progression of signs and symptoms.
3. It is likely to change management.
Undertake a physical examination, which could include neurological screening tests, assessment of mobility and/or muscle strength.
Patient progress should be evaluated including the use of outcome measures.
Provide patients with education, information about their condition and management options.
Provide management addressing physical activity and or exercise.
Apply manual therapy only as an adjunct to other evidence based treatments.
Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.
Facilitate continuation or resumption of work.

Many of these are routinely neglected by family doctors and healthcare professionals with minimal training, like many massage therapists, who can be forgiven for not being musculoskeletal medicine experts, regrettable as it is. Unfortunately, this paper is newsworthy because so many of these best practices are actually neglected by — or even at odds with — the common beliefs and practices of healthcare professionals who should know better. For instance, the importance of psychosocial factors is either entirely neglected or hotly contested by many; or it is paid lip service but given short shrift in practice. There is an immense gap between theory and practice in musculoskeletal medicine, with vast numbers of professionals perpetually indulging in pet theories of pain and wildly overestimating the value of passive therapies — the power of gadgets, tools, and hands — while underestimating and neglecting everything else.

Not that it’s a perfect list! There are problems here too. The consensus of several recent clinical practice guidelines is not necessarily the last word, and I would hope that the same review would have some different results ten years from now.

~ Paul Ingraham

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

OBJECTIVES: To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs).

DESIGN: Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations.

ELIGIBILITY CRITERIA: Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.

DATA SOURCES: Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories.

RESULTS: 6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work.

CONCLUSION: These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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