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  • Study Identifies 11 Guideline-Based Recommendations for Musculoskeletal Pain

    A multidisciplinary group of researchers, including physical therapists (PTs), has identified a core set of 11 clinical practice guideline (CPG) recommendations for treating adult musculoskeletal (MSK) pain, according to a new article in British Journal of Sports Medicine (BJSM). Authors hope the recommendations will assist emergency and primary care clinicians in providing evidence-based care, as well as help consumers make informed health care decisions.

    Authors write that while "care that is more concordant with CPG recommendations results in better patient outcomes and lower costs," providers across disciplines too often do not practice according to guidelines, resulting in overuse of imaging, surgery, and opioids, and a failure to provide patient education and advice. There are many reasons for this, according to authors: CPGs often are not "user-friendly"; they often lack guidance on how to implement recommendations in practice; and different guidelines for a single condition may include conflicting recommendations.

    To help bridge these "evidence-to-practice gaps"—and help consumers understand what best practice looks like—authors examined 44 CPGs addressing 3 of the most common areas for MSK: spinal pain; hip/knee pain, including hip/knee osteoarthritis; and shoulder pain. The CPGs reviewed were published within the last 5 years, included information on how they were developed, and were published in English. Researchers excluded guidelines that focused on a single treatment modality, traditional medicine, traumatic MSK pain, specific diseases such as inflammatory arthritis, and those that required payment to access.

    Included in the analysis was the Academy of Orthopaedic Physical Therapy guideline "Low back pain: clinical practice guidelines linked to the international classification of functioning, disability, and health."

    Authors performed an AGREE II analysis on each CPG. A guideline was classified as "high-quality" if it received an AGREE II score that was at least half of the maximum possible score in 3 separate areas: rigor of development, editorial independence, and stakeholder Involvement.

    The 11 consistent recommendations include:

    1. Care should always be patient centered. Patient-centered care, according to authors, is characterized by effective communication, individualized care, shared decision making, and prioritizing patient preferences.
    2. Patients should be screened for serious pathology or "red flag" conditions. Providers should screen for causes of pain such as infection, malignancy, fracture, inflammation, neurological deficit, as well as conditions that mimic MSK pain.
    3. Psychosocial factors should be included in a patient's assessment. Providers should assess patients for psychosocial factors—such as depression, anxiety, kinesiophobia, and recovery expectations—that may affect their prognosis, in order to develop an appropriate plan of care.
    4. Radiological imaging is unnecessary in most cases. Many guidelines discourage the use of radiological imaging, except when a more serious pathology is suspected, the patient is not responding to treatment, or the imaging results are "likely to change management" of the patient's condition.
    5. Assessment should include physical examination to assist in diagnosis and classification. Physical assessments mentioned in the CPGs include tests for mobility/movement, strength, position and proprioception, and neurological function.
    6. Providers should evaluate patient progress and use validated outcome measures. In the CPGs authors examined, outcome measures assessed patients' pain intensity, functional capacity and activities of daily living, and quality of life.
    7. Patients should receive individualized education about their condition and treatment options. Authors recommend patient education to "encourage self-management and/or inform/reassure patients about the condition or management."
    8. Treatment should address physical activity and exercise. All of the CPGs reviewed included recommendations on either general or specific exercise and physical activity to increase mobility, strength, and flexibility.
    9. Manual therapy should be used only as an adjunct treatment. Seven CPGs included manual therapy as a "could-do" element of care, but only as part of a more comprehensive plan of care.
    10. Nonsurgical care should be the first line treatment. Unless a "red flag" condition indicates otherwise, patients should receive nonsurgical care before considering surgery.
    11. Treatment should facilitate return to work. Providers should encourage patients to remain active and engage with appropriate social service supports, employers, and health providers to enable a patient to return to work.

    Looking beyond the clinical application of the recommendations, authors suggest that a "broader strategy" for policy makers and health services researchers "could be the continued development of the common recommendations into a set of quality indicators that could be used for reporting or to benchmark care quality."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • It is a shame that manual therapy is not considered a primary PT intervention for musculoskeletal disorders, simply based on the issue of the need for additional research on the work. I guess that explains why patients are choosing to see their hands-on massage therapist instead of the PT, and paying cash for the services, since they are not receiving much manual therapy for their problems from their physical therapist. As a PT and massage therapist, I recognize the value of manual therapy, despite the need for more evidence. As a patient who has benefited from the manual therapy offered by LMTs when my local PTs failed to provide it, I will not hesitate to pay in full for massage when the local PT only gives me exercises I could perform on my own. It is time for our profession to support more research on what we do best, and publish it. The Fascia Research Congress has published extensively on the value of manual therapy.

      Posted by Theresa A Schmidt on 5/29/2019 12:24 PM

    • This article left me scratching my head in bewilderment. This is the latest research? This is the best they could come up with? These recommendations have been self evident for decades. Most of what is stated here is PT 101 ... or at least should be. The quality of so much modern research truly leaves much to be desired.

      Posted by Brian Miller on 5/29/2019 5:50 PM

    • hmmm, let's think about the message from this piece (and two alternate messages). Two are devoid of evidence (and clearly not accurate)...one not so much...Perhaps we could (should?) rethink our interpretation of the available literature and, thus messaging. 1) Radiological imaging is unnecessary in most cases (as above) 2) Radiological imaging is necessary in most cases 3) Radiological imaging is necessary in some cases

      Posted by James Elliott -> >IU\@G on 5/29/2019 6:32 PM

    • Really!? This is the quality of research we are sharing with our APTA membership? I would NOT give this to a patient and not any of my students. A PT student wouldn’t dare turn this in for academic credit.

      Posted by Bruce C. Diven, DPT on 5/30/2019 9:07 AM

    • Manual therapy should be primary intervention. Exrrcise therapy, education about the condition, pain neuroscience and ecrrcisr therapy are adjuncts to treating MSK disorders. During assessment, if there is an indication, radiology shoukd be included to assist with a diagnosis. Having said that, dhoukf a patient present with radiological investigations, it's important yo assess tge patient before having aoom at the radiology We emphasise that we treat people not rad iographs

      Posted by Shamim khan on 5/31/2019 1:42 AM

    • It is interesting to note that the McKenzie Method satisfies all 11 recommendations, and in the area of lower back pain has the most scientific support of any conservative approach, but is not standard practice in our profession. What's up with that?

      Posted by James C. McGavin, PT, MSc, DipMDT on 6/6/2019 11:23 AM

    • I'm a little surprised at the hostility in the comments section for this post. The cornerstone of managing MSK pain (note: not function) is driving patient self efficacy. All of the 11 items listed relate, in some fashion, to facilitating this. I totally agree that many of these are obvious, and have been well represented in PT practice for decades, but many, such as the psychosocial factors for instance, are having a renewed interest as key elements to pain science. The findings for Manual Therapy as an adjunct treatment is spot-on, particularly in those cases where MSK pain lingers into chronic. It's great for many conditions, but it belongs in the earlier part of the treatment. As treatment progresses, a transition to focus on education and self management strategies are key to allow the patient to have continued success past the episode in the clinic. If we as a profession are relying on manipulation and mobilization as our primary treatment modality for pain control, we're going to fail a good portion of our patients, and run the risk of driving them to other treatment strategies that come with greater risk (eg surgery) and not necessarily better reward than if we had done our job better in the first place.

      Posted by Sean Kinsman on 8/30/2019 12:34 PM

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