Detailed guides to painful problems, treatments & more

Reality versus best practices in musculoskeletal medicine

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

How do the best healthcare professionals tackle the medicine of aches, pains, and injuries? What are the habits of highly effective doctors, physical therapists, massage therapists, chiropractors? For a recent paper in British Journal of Sports Medicine, Lin et al gave us a list. They distilled several key best practices from eleven recent English clinical practice guidelines (out of a pool of dozens of candidates).

Here are those best practices, in my words (but closely following the source):

  1. Look for warning signs of serious conditions. (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, and 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 😜)
  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 their hands or equipment (manual or passive therapy) should only be used in addition to other evidence-based treatments.

That last one is a doozy

Fully taken to heart, that final priority would plunge entire professions and industries in obsolescence. (Which ones? I leave that as an exercise for the reader.)

Some readers will have trouble believing 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 years for many reasons. Hell, the journal of Manual Therapy actually changed its name to Musculoskeletal Science & Practice.?

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.

The best practices are not practiced much

Otherwise these best practices all sound pretty straightforward, don’t they? But the story here is that many of these best practices are alarmingly missing in action. Most are routinely neglected by family doctors and healthcare professionals with minimal training in musculoskeletal medicine (like the majority of massage therapists, who can be forgiven for not being experts, regrettable as it is).

Manual/passive treatments (like massage therapy, spinal “adjustment” & 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 are still 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.

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.

Lip service is almost always paid to exercise, but it is prioritized with way too much enthusiasm for the least valuable approach: the corrective exercise trap. The trap, basically, is 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 exercise that should usually be prescribed.

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 guide the average clinician.