Posts in category: Pain And Its Management

There is an interesting phenomenon in the realm of neuroscience and memory where each time you recall the past your brain networks change in a way that can alter the later recall of the past. 

Why bring this up in a musculoskeletal pain post?

I would argue that as often as we want to believe we are correct about something, it may be important to review what we think we know and (especially with regards to medical research) look to see if something has changed over the past year … or two … or five … or ten … or twenty…

A 2019 systematic review by Lin et. al. in the British Journal of Sports Medicine reviewed 44 clinical practice guidelines finding eleven consistent guidelines for best practice care of musculoskeletal pain.

Two things worth noting before we get into the eleven guidelines.

1. Clinical practice guidelines (or CPGs) are a synopsis of, typically, high-quality and current evidence to help — wait for it — guide clinical practice for more efficient and effective care. As it can be challenging to balance busy clinical care and keeping up with the thousands of medical research articles that are published every year, these CPGs can help to streamline the literature to practitioner flow… Ultimately, they have been found to result in better patient outcomes and lower costs.
2. What is musculoskeletal pain and why is it a problem?
   • Musculoskeletal pain conditions are the biggest cause of disability internationally and include pain that arises from the muscular and/or skeletal systems. 
   • Worth noting from the background of the Lin et. al. article:
     • There is an overuse of medical imaging with between 25% and 42% of those with low back pain receiving this despite its routine use being discouraged secondary to the associated harms.
     • There is an overuse of surgery where, for example, arthroscopy for knee osteoarthritis is not recommended yet has an increased rate of use in the US from 2006 to 2010, and we see an increased rate of subacromial decompression at the shoulder despite comparable outcomes with exercise-based rehabilitation and sham surgery. Yes, you read that correctly, the real and fake surgery have comparable outcomes…
     • There is an overuse of opioids despite questionable efficacy of opioids for musculoskeletal pain (both chronic and acute), evidence for poorer outcomes with individuals suffering from low back pain, and notable opioid-related harms. 
     • Lastly, these is a failure to provide appropriate education and advice where only 20% of individuals have been found to receive education in the primary care setting. This is considered the cornerstone of managing musculoskeletal pain conditions. 

Ok, referring back to the portion above – do we know what we think we know? And, if we know it, are we doing the best things?

So what ‘should’ we be doing? Per the Lin et. al. (2019) article: 

1. Care should be patient centered.
   • This includes care that responds to the individual context of the patient, employs effective communication and uses shared decision-making processes.
2. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions.
   • Examples included suspicion of infection, malignancy, fracture, inflammatory causes of pain, severe and progressive neurological deficit (including cauda equina syndrome) and serious conditions that masquerade as musculoskeletal pain, for example, aortic aneurysm
3. Assess psychosocial factors.
   • These factors included ‘yellow flags’, mood/emotions (depression and anxiety), fear/kinesiophobia and recovery expectations.
4. Radiological imaging is discouraged unless:
   • i. Serious pathology is suspected.
   • ii. There has been an unsatisfactory response to conservative care or unexplained progression of signs and symptoms.
   • iii. It is likely to change management.
5. Undertake a physical examination, which could include neurological screening tests, assessment of mobility and/or muscle strength.
   • “the repercussions of not performing an examination would lead to dissatisfaction and unwarranted demand for tests or further referrals”
6. Patient progress should be evaluated including the use of outcome measures.
7. Provide patients with education/information about their condition and management options.
8. Provide management addressing physical activity and/or exercise.
9. Apply manual therapy only as an adjunct to other evidence-based treatments.
   • Manual therapy was consistently recommended as a component of multimodal care, in conjunction with other management strategies, including exercise, psychological therapy, information/education, and activity advice rather than a stand-alone treatment
10. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.
    • There is literally an army of conservative practitioners ready and willing…
11. Facilitate continuation or resumption of work. 

As a quick aside and to reiterate #1, it’s important to keep in mind that what may be appropriate for any given individual is specific for that individual. This is why Google is not good at diagnostics and why your doctors hold a doctoral degree. Just important things to keep in mind…

With regards to more specific recommendations within a single pain condition:

• Osteoarthritis (OA)
  • Offer self-management programmes.
  • Provide interventions targeting weight loss to people with OA who are overweight or obese.
  • Do not use glucosamine or chondroitin for disease modification.
  • Do not undertake knee arthroscopic lavage and debridement unless there is a rationale (such as mechanical knee locking).
• Low back pain
  • Do not offer paracetamol as a single medication.
  • Do not offer opioids for chronic LBP.
  • Do not offer selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants or anticonvulsants for LBP.
  • Do not offer rocker shoes or foot orthotics.
  • Do not offer disc replacement.
  • Only offer spinal fusion if part of a randomised controlled trial.
  • Spinal injections (eg, facet joint injections, medial branch blocks, intradiscal injections, prolotherapy and trigger point injections) should not be used for LBP.
• Neck pain
  • Neck pain disorders should be classified as grades I–IV.

So, as a clinician, are you using best evidence to care for your patients? AND, as a client or patient are you asking for and getting what is best for your care? 

Thanks for reading!