Research Review By Dr. Ceara Higgins©


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Date Posted:

September 2019

Study Title:

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review


Lin I, Wiles L, Waller R, et al.

Author's Affiliations:

University of Western Australia, Australia; University of South Australia, Australia; Curtin University, Perth, Australia; Sir Charles Gardner Hospital, Perth, Australia; Harry Perkins Institute of Medical Research, Perth, Australia; Fiona Stanley Hospital, Murdoch, Australia; Geraldton Hospital, Geraldton, Australia; Sydney Medical School, Australia.

Publication Information:

British Journal of Sports Medicine 2020; 59: 79-86. Mar 2. pii: bjsports-2018-099878. doi: 10.1136/bjsports-2018-099878. [Epub ahead of print]

Background Information:

Internationally, musculoskeletal (MSK) pain conditions are the largest cause of disability (1) and a major burden on society. Common healthcare problems related to MSK pain include overuse of radiological imaging, surgery and opioids, as well as failure to provide education and advice to patients. These practices waste healthcare resources and result in suboptimal care for patients.

Clinical practice guidelines (CPGs) aim to improve care by guiding clinical and patient decision making, providing a (reference for) standard of care, contributing to the development of aids to clinical decision making, informing stakeholders about best practices, and guiding the distribution of healthcare resources (2). Care that follows CPG recommendations leads to lower costs and better patient outcomes (3). However, CPGs have been criticized for being difficult for clinicians to use due to the multitude of CPGs for single conditions, being voluminous and not user-friendly, having issues with quality, lacking transparency in development (4), using inconsistent terminology, over-representing some conditions and under-representing others, and failing to outline how to implement their recommendations.

This study aimed to identify a common set of recommendations from high-quality CPGs that could be used to assess and manage a wide range of MSK pain conditions.

Pertinent Results:

44 CPGs (including 15 for LBP, 14 for OA, 6 for shoulder conditions, 5 for neck conditions, and one each for neck/thoracic spine, knee, “MSK injuries”, and lower limb) were selected. All included CPGs (except one from Malaysia and one from the Philippines) originated or involved panel members from high-income countries. These included CPGs from the USA, “international”, Canada, The Netherlands, United Kingdom and Italy. Following assessment using the AGREE-II instrument, 8 high-quality MSK pain CPGs were identified for OA and shoulder pain, 10 for LBP, and 9 for neck pain.

Common/consistent recommendations were identified as follows:
  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. Practitioners should screen patients to identify those with a high likelihood of serious pathology/red flag conditions.
  3. Psychosocial factors should be assessed - These should include yellow flags, mood/emotions, fear, kinesiophobia, and recovery expectations. Recommendations for LBP included using the STarT Back or Orebro Musculoskeletal Screening tools.
  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; or iii) imaging is likely to change management - it is also recommended to explain to patients that imaging may not be needed.
  5. Assessment should include physical examination. Physical examination could include neurological screening tests, mobility, and/or muscle strength - mobility/movement testing, strength, and position and proprioception were recommended for all conditions, where tests for neurological function were recommended for spinal pain.
  6. Patient progress should be evaluated, including the use of validated outcome measures - recommended outcome measures include a seven-point patient self-rated recovery questionnaire, pain intensity, functional capacity/activities of daily living, and/or quality of life.
  7. All patients should be provided with education/information about their condition and management options - this should be aimed at encouraging self-management, and/or informing/reassuring patients about their condition or management. In all CPGs, this was recommended as part of multimodal care alongside other treatments. This should be individualized to the patient.
  8. Patients should receive management that addresses physical activity and/or exercise - CPGs for OA, LBP and neck pain recommended maintaining “normal” physical activity, performing aerobic exercise, or exercising in general. CPGs for OA strongly recommended strengthening, mobility exercises including range of motion and stretching, water-based exercise, neuromuscular education, or tai chi. A single CPG for rotator cuff injuries recommended stretching, flexibility, and strengthening. CPGs for LBP and neck pain recommended supervised exercise.
  9. If used, manual therapy should only be applied in conjunction with other treatments - manual therapy was recommended as a “could do” in seven CPGs, and as “should do” in only one CPG. However, it was always recommended as one component of multimodal care along with exercise, psychological therapy, information/education, and/or activity advice rather than as a stand-alone therapy.
  10. Unless specifically contraindicated (i.e. “red flag” condition[s]), offer evidence-informed non-surgical care prior to surgery - duration of non-surgical care was only specified in one CPG on rotator cuff injuries, which recommended considering surgery only if 3 months of non-surgical management was unsuccessful and/or if a symptomatic, full thickness rotator cuff tear was discovered on review.
  11. Facilitate continuation or resumption of work - CPGs for neck pain, OA, LBP, and rotator cuff syndrome recommended re-engagement with or continuation of work, with an emphasis on early return to work.
Additional recommendations were identified for single MSK pain conditions (listed below). CPGs revealed conflicting recommendations between MSK pain conditions and within specific conditions for medication prescription (including prescription of opioids), electrotherapy, use of braces and orthoses, and acupuncture.

Consistent recommendations within single MSK pain conditions:

Osteoarthritis (OA):
  1. Offer self-management programs.
  2. Provide information targeting weight loss to people with OA who are overweight or obese.
  3. Do not use glucosamine or chondroitin for disease modification.
  4. Do not undertake knee arthroscopic lavage and debridement unless there is a rationale (such as mechanical knee locking).
Lower Back Pain:
  1. Do not offer paracetamol as a single medication.
  2. Do not offer opioids for chronic LBP.
  3. Do not offer selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants or anticonvulsants for LBP.
  4. Do not offer rocker shoes or foot orthotics.
  5. Do not offer disc replacement.
  6. Only offer spinal fusion if part of a randomized controlled trial
  7. Spinal injections (e.g. facet joint injections, medical branch blocks, intradiscal injections, prolotherapy, and trigger point injections) should not be used for LBP.
Neck Pain:
  1. Neck pain disorders should be classified as grades I-IV.

Clinical Application & Conclusions:

Consistent recommendations across MSK pain conditions were identified to help provide clinicians, healthcare managers, funders, policy makers, and researchers with an easily understood consensus of current MSK pain priorities. These recommendations could be used to help consumers make informed healthcare decisions or help them to identify when they were receiving suboptimal care. As well, clinicians can use these recommendations to guide clinical decision making, identify areas for learning and development, and to assess their practice. Finally, these recommendations could be used to help health services assess quality of care by applying these as minimum standards of care.

Study Methods:

The authors conducted a systematic review and synthesis of CPGs for MSK pain in three of the most common sites for MSK pain; spinal pain (lumbar, thoracic, and cervical spine), hip/knee pain (including hip/knee OA), and shoulder pain. Articles were included if they were published between 2011 and 2017, aimed at adults, available in English, reported on developmental processes, and were an original body of work. CPGs were excluded if they were for traumatic MSK pain, a single treatment modality, traditional healing/medicine, specific disease processes, or were private and required payment for access.

Article titles/abstracts were reviewed by a single author, and then full text articles were reviewed independently by two authors. Finally, three authors independently appraised selected articles for quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. The authors classified articles reaching an AGREE-II score of 50% or greater in three domains (rigour of development, editorial independence, and stakeholder involvement) as high-quality.

Data synthesis included extracting CPG recommendations, classifying recommendations (as “should do”, “could do”, “do not do”, or “uncertain”), developing a narrative summary and where possible, identifying consistent/common recommendations across MSK conditions. Common recommendations within each MSK pain condition were also identified. Two independent authors extracted and classified the recommendations and then one author developed the initial narrative summary. This was then reviewed and refined by all 9 authors. The author group included three academic and practicing physiotherapists, two MSK pain researchers, an indicator development researcher, a specialist emergency care physician, a senior medical officer in emergency medicine and a pain medicine physician.

Recommendations were identified as consistent where there was a majority of “should do” or “do not do” recommendations, no other conflicting recommendations, and the recommendations applied across at least 3 MSK pain conditions.

Study Strengths / Weaknesses:

  • This research group was inter-professional and included both researchers and clinicians. This increases the likelihood that their recommendations will be applicable to clinical practice.
  • The investigators used their own criteria for CPG quality based on the AGREE II instrument. They acknowledged that this approach creates the potential for bias as CPGs were included or excluded based on non-empirically derived criteria.
  • The AGREE II instrument is optimally applied with four individuals appraising the CPGs. In this study only 3 authors appraised the CPGs.
  • Only CPGs available in English were included in this study.

Additional References:

  1. Vos T, Abajobir AA, Abate KH et al. 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. The Lancet 2017; 390: 1211-1259.
  2. IOM (Institute of Medicine). Clinical practice guidelines we can trust. Washington (DC): National Academics Press 2011.
  3. Childs JD, Fritz JM, Wu SS, et al. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. BMC Health Serv Res 2015; 15: 15.
  4. Scott IA, Guyatt GH. Clinical practice guidelines: the need for greater transparency in formulating recommendations. Med J Aust 2011; 195: 29.