Monday, 24 Feb 2020

You are here

Best Practice Recommendations in Musculoskeletal Care

A group of Western Australian clinicians have set out to assess current practices and proved guidance recommendations for high-quality care for the most common musculoskeletal (MSK) pain scenarios encountered by clinicians in emergency and primary care. They have promulgated 11 high-quality clinical practice guidelines (CPGs).

After a systematic literature review and critical appraisal of 44 CPGs,  11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder.

Along the way they found pitfalls: 

  • Overuse of imaging: between 25% and 42% of patients with low back pain (LBP) undergo imaging even though its routine use is discouraged and associated with harms. 68% of general practitioners would refer patients for radiography at first presentation of rotator cuff tendinopathy and 82% would refer for ultrasound, despite findings demonstrating a poor relationship of imaging findings with symptoms.
  • Overuse of surgery: knee arthroscopy for knee osteoarthritis is not recommended, yet its rate of use in the general US population increased from 3% to 4% from 2006 to 2010. The rates of shoulder subacromial decompression and rotator cuff repair have increased markedly even though surgical outcomes are comparable with exercise-based rehabilitation or sham surgery.
  • Overuse of opioids: the efficacy of opioids for MSK pain management is questionable for both chronic and acute MSK pain conditions. The early use of opioids has been associated with poorer outcomes in LBP care. Although limiting the use of opioids is recommended,44 there is increasing use and an ‘epidemic’ of prescription opioid-related harms.

They identified 11 recommendations for MSK pain care: 

  1. Care should be patient centred. 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.
  3. Assess psychosocial factors.
  4. Radiological imaging is discouraged unless: a) Serious pathology is suspected; b) There has been an unsatisfactory response to conservative care or unexplained progression of signs and symptoms; or c) It is likely to change management. 
  5. Undertake a physical examination, which could include neurological screening tests, assessment of mobility and/or muscle strength.
  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. 
  10. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery. 
  11. Facilitate continuation or resumption of work.
The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

Adverse Effects of Low-Dose Methotrexate from the CIRT Trial

Low-dose methotrexate (LD-MTX) was studied in high risk cardiac patients in the cardiac intervention trial (CIRT), but was prematurely ended for not showing a change in cardiovascular event rates. Nonetheless this trial studied the safety and adverse event rates of LD-MTX and those results are reported in the current issue of Annals of Internal Medicine.

Aspirin after Hip or Knee Arthoplasty

JAMA Internal Medicine has reported that use of low dose aspirin for venous thromboembolism (VTE) prophylaxis after total hip and knee replacement is equal in efficacy to other anticoagulants.

NSAIDs May Impair Healing if Taken Nightly

A new study in Scientific Reports suggest that circadian rhythms play an important role in wound healing, and that nonsteroidal anti-inflammatory drugs (NSAIDs) may be disruptive if taken at night given primary healing that occurs in a body at night. 

QD Clinic - "Doc, When Can I Stop?"

QD Clinic - Lessons from the clinic. In this video: Patients stable on a biologic need guidance on when, and if, they can stop their biologic.

QD Clinic - Dealing with Non-adherence

QD Clinic - Lessons from the clinic. Today’s clinic topic: Dealing with Non-Adherence in the Clinic.