CASE REPORTS: A middle-aged patient with slow onset shoulder pain was concerned about the results of a left shoulder ultrasound that showed a partial tear in the rotator cuff. Since the result they had worn a sling to protect the shoulder from “further tearing”.

This patient had a one-year history of disabling low back pain, and depression, worse since she separated from her partner. For six months they had been prescribed repeat oxycodone and celecoxib. There had been no engagement with allied health.

Dr Roger Goucke, Pain Specialist

Dr Roger Goucke, Pain Specialist

Further questions would determine whether their health care management was of high quality. Unfortunately, clinicians such as doctors, physiotherapists, chiropractors, osteopaths and others who work with patients with musculoskeletal pain, don’t always practice in a way consistent with research evidence. Over-use of imaging, the prescription ‘opioid epidemic’, increases in unproven surgeries, and a failure to provide patients with self-management advice are just some of the problems.

We need to change the way musculoskeletal pain is managed.

A recent systematic review of contemporary musculoskeletal pain clinical guidelines may help with starting this change. We were interested in whether, across musculoskeletal pain conditions, we could identify common recommendations to manage musculoskeletal pain. We thought if we could, it would provide consumers, clinicians, educators and health decision makers with a way of knowing what higher quality care of musculoskeletal pain looked like.

Unfortunately, not all musculoskeletal pain guidelines were rigorously developed or reported. However, we were able to rank 11 (out of 32) clinical practice guidelines as high quality. From these we identified 11 common recommendations for the care of musculoskeletal pain conditions.

  1. Care should be patient centred; it responds to the individual context of the patient, employs effective communication and shares decision-making.
  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:
    1. Serious pathology is suspected.
    2. There is an unsatisfactory response to conservative care or unexplained progression of signs and symptoms.
    3. It is likely to change management.
  1. Do a physical examination, including neurological screening tests, assessment of mobility and/or muscle strength.
  2. Evaluate patient progress, including the use of outcome measures.
  3. Provide education/information about their condition and management options.
  4. Provide management addressing physical activity and/or exercise.
  5. Apply manual therapy only as an adjunct to other evidence-based treatments.
  6. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.
  7. Facilitate continuation or resumption of work.

We also identified treatments for certain conditions that should not be provided. For example, patients with low back pain should not be prescribed opioid-based medications or paracetamol alone, given rocker shoes or orthotics, receive disc replacement surgery, or injections into the back when there was no leg pain associated with back pain. Patients with osteoarthritis should be wary of having arthroscopic knee surgery. Many clinicians will not find these recommendations new.

To assist clinicians and patients we have developed an infographic to use as a simple communication tool (Figure 1). Infographics in Italian, German and Portuguese have surfaced online and may be useful for patients who prefer these languages

Fig 1:

See: – We urge readers to review these recommendations, critique them, send us some (constructive) feedback – good or bad.  

The author acknowledges help in writing this article from Dr Ivan Lin.

Reference: 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 2019:bjsports-2018-099878.

Questions? Contact the editor.

Author competing interests: nil relevant disclosures.

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