TAKING OWNERSHIP IN YOUR TREATMENT PATHWAY

What you should know about musculoskeletal pain treatment guidelines for clinicians

The biggest cause for disability internationally are musculoskeletal pain conditions (e.g. knee pain, lower back pain, shoulder pain) [1]. Many factors contribute to these conditions, but data suggest poor quality healthcare can be part of it [2]. If you are a patient with musculoskeletal pain, your likelihood of achieving a good treatment outcome increases if you are well educated about your condition and the treatment process. The job of your health care provider of choice should be to help you in this process and therefore avoid the chance of you having to navigate the endless online library of false wisdom. Being informed about what good practice for treatment of musculoskeletal pain looks like can be helpful for you and aid your decision making about treatment pathways your health care provider may suggest.

Systematic reviews of research data are the type of publications in scientific literature that show us where the large part of the accumulated evidence from multiple studies points us towards to. That kind of data is likely to influence clinical practice guidelines which influence the decision making of health care providers. The British Journal of Sports Medicine recently published a systematic review of 34 clinical practice guidelines that were developed between January 2011 and September 2016 [3] – ensuring assurances if you may. If there is evidence out there you can trust, this should be it.

Common problems identified were the overuse of the following three components: imaging, surgery and opioids [3]. Whilst this does NOT indicate that these components of treatment should be fully avoided, it should be considered whether other options are available or if the three noted pathways are necessary for you. The fourth identified problem was a failure to provide education and advice with data suggesting only 20% of patients with LBP were provided this in a primary care setting [3, 4]. In my opinion this is a problem. Too often I see patients who have been avoiding activity because they have been unsure about their condition, or patients who in a desperate search for answers have put their questions to Dr. Google – with a disadvantageous outcome in most cases.

What can you do?

The new systematic review [3] found eleven consistent recommendations across musculoskeletal pain conditions (see picture 1). Being aware of these may enable you take better ownership in your treatment pathway and make you feel less uncertain and more empowered about your journey.
Picture 1. Adapted from Lin I et. al. 2020

The following is what you should consider:

• Care should be patient centred and respond to the individual context of the patient, use good communication and include the patient in the decision making.
• Don’t be surprised if your health practitioner is assessing psychosocial factors. Research has shown us repeatedly that psychological (e.g. behaviours, emotions, moods) and social (e.g. education, social support, relationships) factors can influence musculoskeletal pain. Using treatment approaches that address these can have astounding impact. In fact, it may be worth for you to mention challenges you are dealing with in your life currently even if your health practitioner does not ask you questions regarding this.
• Accept and don’t be surprised if your health practitioner may not consider imaging (e.g. X-Ray MRI) to investigate further. Evidence has shown that imaging can have negative affects when managing musculoskeletal pain and often don’t change management.
• If you don’t receive education about your condition and treatment, then ask for it.
• Passive treatment (e.g. manual therapy, massage etc.) may be helpful initially, but in the majority of cases your health care provider should use other evidence-based treatments to treat your condition. Ask for advice on how to stay active despite the injury/condition and how to include regular exercise in your lifestyle.

Whilst many factors influence the outcome when treating musculoskeletal pain, we hope this article helps you to determine whether you are receiving effective and high-quality treatment. We encourage you to ask questions when you are with your health care provider to make the process as clear to you as possible and understand your condition.

References:

1. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Vos T, Abajobir AA, Abate KH, et al. The Lancet 2017, 390, 1211–59
2. Low back pain: a call for action. Buchbinder R, van Tulder M, Öberg B, et al. Lancet 2018, 391, 2384–8
3. Lin I, Wiles L, Waller R et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high quality clinical practice guidelines: systematic review. Br J Sports Med 2020, 54, 79–86
4. Low back pain and best practice care: a survey of general practice physicians. Williams CM, Maher CG, Hancock MJ, et al. Arch Intern Med 2010, 170, 271–7