Reality versus best practices in musculoskeletal medicine

What are the habits of highly effective doctors, physical therapists, massage therapists, chiropractors? How do the finest healthcare professionals tackle the challenge of persistent pain and tricky injury rehab challenges? A paper in the British Journal of Sports Medicine by Lin et al. gave us a list of best practices. They distilled several of them from eleven clinical practice guidelines (from a pool of dozens of candidates).

Here are those best practices, in my words, but carefully honouring the source (with parenthetical editorial comments from me):

1. Look for red flags. (Which, of course, requires both broad and deep knowledge of the extraordinary number of surprising causes of pain, many of them subtle and hard to diagnose.)
2. Always do a thorough physical exam. You never know what will turn up!
3. Radiation is bad! Avoid imaging, unless serious pathology is suspected (for instance if the problem is puzzlingly persistent despite the absence of other red flags).
4. Care should revolve around the patient: lots of active listening, decisions get made together, and care is adapted to the unique situation of the patient. No one-size-fits-all medicine.
5. Emphasize the role of lifestyle factors like stress, economic status, sleep quality, and much more.
6. Patient progress should be measured objectively whenever possible, and success should be defined (for instance, “getting back to work” is a clear goal and usually a high priority).
7. Educate patients! Give them as much information about their conditions and options as time allows. (And, when time does not allow, send them to PainScience.com. 😜)
8. Integrate exercise and physical activity into treatment as much as possible.
9. Surgery is a last resort (unless it is specifically needed for an ominous condition, obviously).
10. Any treatment that is done to the patient — with either hands or tools, manual or passive therapy — should only be used in addition to other evidence-based treatments.

That last one is a doozy: minimizing the manual

Demoting manual therapy to be a mere side dish to the entreé of "evidence-based medicine" — basically everything else in that list — would plunge whole professions and industries in crisis and obsolescence. (Which ones? I leave that as an exercise for the reader.)

Many readers will have trouble accepting that “best practices” means sidelining most of what they do for a living, but this is not coming out of nowhere: MSK medicine has been moving away from manual/passive therapy for many years for many reasons. This is why the journal of Manual Therapy actually changed its name to Musculoskeletal Science & Practice … back in 2017.1

This is happening because (in broad strokes), after decades in the oven, most manual therapy remains half-baked and unimpressive, consistently performing poorly in clinical trials. The debate rages on and manual therapists are not just going to walk away without a fight. But the controversy is real.

The best practices are not practiced much

Otherwise these best practices all sound pretty straightforward, don’t they? Almost suspiciously ordinary and obvious.

And yet many of these best practices are alarmingly missing in action. Many are routinely neglected by family doctors and healthcare professionals with minimal training in musculoskeletal medicine — like most massage therapists.

Manual/passive treatments (like massage therapy, spinal “adjustment” and so on) are declared second class citizens in good musculoskeletal medicine; they “should only be used in addition to other evidence-based treatments” (Lin et al.). And yet they remain the main course of most therapy in the real world.

More troubling is that so many professionals who should know better also struggle to get the basics right. There is an immense gap between theory and practice, with pros routinely 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. Some examples:

• The importance of psychosocial factors is either entirely neglected or hotly contested by many. Or it gets lip service, but given short shrift in practice. Or it is applied clumsily, fetishized and oversimplified to just diagnosing people as stressed and anxious.
• Exercise gets plenty of attention, but is also corrupted by oversimplification, with the vast majority of it falling into the corrective exercise trap — the belief that specific, technical exercises intended to “fix” people are much more therapeutic and worthwhile than general exercise. They rarely are, if ever. It’s general activity exercise that should usually be prescribed. But that’s not “fancy” enough.
• Red flags are often missed by every kind of professional, but almost perfectly in sync with education — the less knowledge they have, the more likely they are to fail to notice the significance. Knowing enough pathology to spot the clues that an odd pain is the tip of pathologic iceberg is extremely important, but it’s not happening.

So there’s a lot of work to do. As I will continue to point out, probably for the rest of my career, musculoskeletal and pain medicine are still surprisingly “new.” Guidelines like these are still evolving, and have barely even begun to actually guide the average clinician.

Notes

1. Their under-stated explanation:

   The new title will better reflect current practice, education and research in the field of musculoskeletal physiotherapy worldwide and ensure that the journal continues to be a leading publication in the field.

   In other words, “manual therapy” was just too narrow, too much about fixing people with techniques and magic hands, and neglected other perspectives and approaches. The change signalled a general retreat from the belief that flesh and structure need to be changed … or even can be. It is writing on the wall that says that manual therapy needs to get beyond being “manual,” because there’s a lot more to this field than structure.