Models of Care for musculoskeletal pain conditions: driving change to improve outcomes

Patient acceptance of care of a novel care pathway for those at risk of poor outcomes from musculoskeletal pain: A mixed methods study

OBJECTIVE

Investigate people's acceptance of specialist musculoskeletal care within a new care pathway for common musculoskeletal conditions (low back pain, neck pain/whiplash, knee osteoarthritis).

DESIGN

Convergent parallel mixed methods design referencing the Theoretical Framework of Acceptability. The study included a subset of participants (n = 29) at-risk of poor outcomes from the intervention arm of the PAthway of CarE for common musculoskeletal conditions (PACE-MSK) trial. In the PACE-MSK arm, participants received specialist physiotherapist care as an adjunct to the care provided by their primary healthcare professional(s). One-to-one semi-structured interviews were conducted around 3-months after commencing in the trial. Quantitative data were collected at baseline and 3-month follow-up (health-related quality of life, pain self-efficacy, global perceived change, satisfaction).

RESULTS

Five themes were identified (Expectations and beliefs shaped patient experience; Clinical expertise and competence influence acceptance; Person-centred care; Mechanisms facilitating beneficial responses to care; Gaps in care pathway implementation). There were positive individual changes in physical quality of life for 17/29 (59%) participants, mental health quality of life for 12/29 (41%), pain self-efficacy for 8/29 (28%) and global perceived change for 19/29 (66%). Management met expectations with the majority reporting high levels of satisfaction. Integrating the qualitative and quantitative data with the Theoretical Framework of Acceptability, there were complementary meta-inferences in the constructs of 'ethicality', 'intervention coherence', 'self-efficacy' and 'affective attitude'. Divergence was identified in 'perceived effectiveness'.

DISCUSSION

In general, there was positive acceptance of the care pathway by participants. Specialist physiotherapists' care was perceived as a positive addition to usual care.

Assessment of Spinal and Pelvic Kinematics Using Inertial Measurement Units in Clinical Subgroups of Persistent Non-Specific Low Back Pain

Inertial measurement units (IMUs) offer a portable and quantitative solution for clinical movement analysis. However, their application in non-specific low back pain (NSLBP) remains underexplored. This study compared the spine and pelvis kinematics obtained from IMUs between individuals with and without NSLBP and across clinical subgroups of NSLBP. A total of 81 participants with NSLBP with flexion (FP; n = 38) and extension (EP; n = 43) motor control impairment and 26 controls (No-NSLBP) completed 10 repetitions of spine movements (flexion, extension, lateral flexion). IMUs were placed on the sacrum, fourth and second lumbar vertebrae, and seventh cervical vertebra to measure inclination at the pelvis, lower (LLx) and upper (ULx) lumbar spine, and lower cervical spine (LCx), respectively. At each location, the range of movement (ROM) was quantified as the range of IMU orientation in the primary plane of movement. The ROM was compared between NSLBP and No-NSLBP using unpaired t-tests and across FP-NSLBP, EP-NSLBP, and No-NSLBP subgroups using one-way ANOVA. Individuals with NSLBP exhibited a smaller ROM at the ULx (p = 0.005), LLx (p = 0.003) and LCx (p = 0.01) during forward flexion, smaller ROM at the LLx during extension (p = 0.03), and a smaller ROM at the pelvis during lateral flexion (p = 0.003). Those in the EP-NSLBP group had smaller ROM than those in the No-NSLBP group at LLx during forward flexion (Bonferroni-corrected p = 0.005), extension (p = 0.013), and lateral flexion (p = 0.038), and a smaller ROM at the pelvis during lateral flexion (p = 0.005). Those in the FP-NSLBP subgroup had smaller ROM than those in the No-NSLBP group at the ULx during forward flexion (p = 0.024). IMUs detected variations in kinematics at the trunk, lumbar spine, and pelvis among individuals with and without NSLBP and across clinical NSLBP subgroups during flexion, extension, and lateral flexion. These findings consistently point to reduced ROM in NSLBP. The identified subgroup differences highlight the potential of IMU for assessing spinal and pelvic kinematics in these clinically verified subgroups of NSLBP.

Multidimensional characteristics of musculoskeletal pain and risk of hip fractures among elderly adults: the first longitudinal evidence from CHARLS

BACKGROUND

Hip fractures are a major public health concern among middle-aged and older adults. It is important to understand the associated risk factors to inform health policies and develop better prevention strategies. Musculoskeletal pain is a possible implicating factor, being associated with physical inactivity and risk of falls. However, the association between musculoskeletal pain and hip fractures has not been clearly investigated.

METHODS

A nationally representative sample of the Chinese population was obtained from the China Health and Retirement Longitudinal Study (CHARLS). The study collected patient information on their demographic characteristics, socioeconomic status, other health-related behavior, and history of musculoskeletal pain and hip fractures. Univariate and multivariate analyses were conducted to investigate the factors influencing the risk of hip fracture, including factors related to the individual and to musculoskeletal pain. P for trend test was performed to assess the trend of each continuous variable. The robustness and bias were assessed using the bootstrap method. Restricted cubic spline regression was utilized to identify linear or non-linear relationships.

RESULTS

Among the 18,813 respondents, a total of 215 individuals reported that they have experienced a hip fracture. An increased risk of hip fracture was associated with the presence of waist pain and leg pain (P < 0.05), as well as with an increased number of musculoskeletal pain sites (P < 0.05). For individuals aged 65 and above, a significant association was found between age and the risk of hip fracture (P < 0.05). Furthermore, respondents with lower education level had a higher risk of hip fracture compared to those with higher education levels (P < 0.05).

CONCLUSION

In the Chinese population, the risk of hip fracture was found to be associated with both the location and extent of musculoskeletal pain, as well as with other factors such as age and demographic characteristics. The findings of this study may be useful for informing policy development and treatment strategies, and provide evidence for comparison with data from other demographic populations.

Global Cluster Analysis and Network Visualization in Musculoskeletal Pain Management: A Scientometric Mapping

OBJECTIVE

Musculoskeletal pain is the most prominent clinical manifestation of more than 150 musculoskeletal disease conditions, and its effective long-term management poses a great challenge to healthcare systems globally. For this, it is important to understand current research progress on musculoskeletal pain management. The purpose of the present study is to provide a comprehensive insight into the current state of research and global trends in musculoskeletal pain management.

METHODS

Publications on musculoskeletal pain management from 1972 to 2021 were retrieved from the Science Citation Index-Expanded (SCIE) database. Included articles were any article type related to aspects of musculoskeletal pain management, including etiology, mechanisms, epidemiology, treatment, outcomes, side effects, and patient compliance. Publication data were analyzed using bibliometric methods. The software VOSviewer was employed to perform bibliographic coupling, co-authorship, co-citation, and co-occurrence analysis, and to visualize publication tendencies in musculoskeletal pain management.

RESULTS

A total of 5475 articles were included in this study. The number of global publications on musculoskeletal pain management has escalated annually. Based on the number of publications and citations from the published literature, as well as the H-index, the United States led global contributions in this area. The institutions making the highest contributions were the League of European Research Universities (LERU), the University of Sydney, and Harvard University. The journal BMC Musculoskeletal Disorders published the highest number of articles in this area. The published studies fall under six groups: "Prevention and rehabilitation," "Etiology and diagnosis," "Clinical study," "Epidemiology," "Mental health," and "Education." High-quality primary studies and epidemiology are predicted to be the next prevailing topics in this field of research.

CONCLUSIONS

Based on current global trends, the number of publications on musculoskeletal pain management will continue to increase. Future studies will likely place more emphasis on high-quality randomized controlled trials (RCTs) and epidemiological studies.

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care

ABSTRACT

What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

Synthesis of clinical practice guideline recommendations for the primary health care of chronic musculoskeletal pain

RATIONALE AND AIMS

The prevalence of chronic musculoskeletal pain (CMSP) is high and rising. The multidimensional impact of CMSP on individuals necessitates multidisciplinary evidence-based strategies to prevent and manage chronic pain. Primary health care (PHC) is the first point of care in many healthcare systems and evidence implementation at this point is important. We aim to describe the process of development of a comprehensive list of evidence-based recommendations derived from different high-quality clinical practice guidelines (CPGs) to inform the PHC healthcare of adults with CMSP.

METHOD

A systematic review was conducted of CPGs that focussed on PHC management of CMSP in adults. CPGs were identified by searching 13 guideline clearinghouses and five online databases. Eligible CPGs were critically appraised using Appraisal of Guidelines Research and Evaluation, Version II (AGREE II). A stepwise systematic process was followed to identify a core set of recommendations. This process comprised the following: extract recommendations; analyze recommendations; synthesize recommendations by assimilating similar recommendations; determine the strength of the body of evidence underpinning the recommendations and produce a list of synthesized recommendations.

RESULTS

Six high-quality CPGs were identified, providing 156 recommendations. These were condensed to 42 statements covering topics about the approach to care, assessment, advice and education, referral, pharmacological management, physical therapy, electrotherapy, psychological therapy, complementary therapy and self-management. The set of recommendations encompasses a person-centered approach, collaborative decision making, a biopsychosocial approach, patient education and empowerment towards self-management.

CONCLUSION

The process of developing composite recommendations from multiple CPGs enables end-users to access comprehensive information on managing CMSP in PHC settings that is not available from one singular CPG. The content and evidence base for recommendations varied between CPGs. A similar stepwise process may be used to develop a core set of recommendations for other health conditions, where multiple, diverse CPGs exist.

Barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain: a systematic review and qualitative evidence synthesis

ABSTRACT

A substantial evidence-practice gap exists between healthcare professionals learning about the biopsychosocial model of pain and adopting this model in clinical practice. This review aimed to explore the barriers and enablers that influence the application of a biopsychosocial approach to musculoskeletal pain in practice, from the clinicians' perspective. Qualitative evidence synthesis was used. Four electronic databases (CINAHL, EMBASE, MEDLINE, and PsycINFO) were searched. Primary qualitative studies were included if they investigated the experiences of primary healthcare professionals using a biopsychosocial model of musculoskeletal pain care in outpatient settings or their perceptions towards biopsychosocial-oriented clinical practice guidelines. After screening 6571 abstracts, 77 full-text articles were retrieved. Twenty-five studies met the eligibility criteria, reporting the experiences of 413 healthcare professionals (including general practitioners, physiotherapists, and others) spanning 11 countries. Three metathemes were identified that impact the adoption of the biopsychosocial model across the whole of health: (1) at the microlevel, healthcare professionals' personal factors, knowledge and skills, and their misconceptions of clinical practice guidelines, perception of patients' factors, and time; (2) at the mesolevel, clinical practice guideline formulation, community factors, funding models, health service provision, resourcing issues, and workforce training issues; and (3) at the macrolevel, health policy, organizational, and social factors. Synthesized data revealed multilevel (whole-of-health) barriers and enablers to health professionals adopting a biopsychosocial model of pain into practice. Awareness of these multilevel factors may help inform preimplementation preparedness and support more effective implementation of the biopsychosocial model of musculoskeletal pain into clinical practice.

Complementary and alternative medicine use among older adults with musculoskeletal pain: findings from the European Social Survey (2014) special module on the social determinants of health

Background:

This study describes the use of complementary and alternative medicine (CAM) among older adults who report being hampered in daily activities due to musculoskeletal pain. The characteristics of older adults with debilitating musculoskeletal pain who report CAM use is also examined.

Methods:

Cross-sectional European Social Survey Round 7 data from 21 countries were examined for participants aged 55 years and older, who reported musculoskeletal pain that hampered daily activities in the past 12 months.

Results:

Of the 4950 older adult participants reporting musculoskeletal pain that hampered daily activities, the majority (63.5%) were from the West of Europe, reported secondary education or less (78.2%), and reported at least one other health-related problem (74.6%). In total, 1657 (33.5%) reported using at least one CAM treatment in the previous year. Manual body-based therapies (MBBTs) were most used, including massage therapy (17.9%) and osteopathy (7.0%). Alternative medicinal systems (AMSs) were also popular with 6.5% using homoeopathy and 5.3% reporting herbal treatments. A general trend of higher CAM use in younger participants was noted. CAM use was associated with physiotherapy use, female gender, higher levels of education, being in employment and living in West Europe. Those reporting multiple health problems were more likely to use all CAM treatments, except MBBT.

Conclusion:

A third of older Europeans with musculoskeletal pain report CAM use in the previous 12 months. Certain subgroups with higher rates of CAM use could be identified. Clinicians should comprehensively and routinely assess CAM use among older adults with musculoskeletal pain.

Mind the gap - Evaluation of the promotion initiatives for implementation of the GLA:D® back clinician courses

BACKGROUND

Translation of research into practice is a methodological challenge. The GLA:D® Back program was initiated to implement evidence-based care for people with low back pain inspired by GLA:D® (Good Life with osteoArthritis in Denmark) that has succeeded in implementing evidence-based care for knee and hip osteoarthritis. This study evaluates the spread and reach of promotion initiatives for GLA:D® Back clinician courses, and the adoption of the GLA:D® Back intervention in clinical practice.

METHODS

Pre-defined success criteria addressed; i) spread; achievement of intended promotion activities (e.g. social media), ii) reach; recruitment of clinicians with certain profiles (e.g. gender balance). Adoption was defined as patient enrollment in the GLA:D® Back registry by course participants. Univariate and multivariate logistic regression was used to investigate associations between adoption and clinician characteristics.

RESULTS

Most clinicians signed up based on information from colleagues (22%). Pre-defined goals for reach, except one, was obtained. 23% (140) of clinicians initiated the GLA:D® Back program in clinical practice within <90 days of course participation; mainly physiotherapists (p < 0.001). The odds ratio for starting GLA:D® Back patient care in a chiropractic setting was 7.4 [2.5; 21.4], indicating that physiotherapists employed by chiropractors mostly handled the intervention.

CONCLUSION

Future promotion strategies should recognize the influence of colleagues and professional networks. Converting clinician courses into patient care was mostly adopted physiotherapists. Although, evaluation processes were less useful in this study, future evaluation of health care processes has potential to inform the implementation of new models in future studies.

eHealth interventions to support self-management in people with musculoskeletal disorders: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to explore existing literature related to the role of eHealth interventions in supporting self-management in those with musculoskeletal disorders in order to investigate and chart the evidence, and identify any gaps within the literature.

INTRODUCTION

Musculoskeletal disorders are one of the leading causes of disability worldwide. Self-management interventions are consistently recommended as a core component of treatment for people with musculoskeletal disorders. Given limited health care resources, there is increasing interest in the potential role of eHealth interventions to support self-management in this population.

INCLUSION CRITERIA

Studies that include adult participants (older than 18 years) with a musculoskeletal disorder will be considered. Studies that include participants with pain of specific pathological origin (eg, infection, malignancy, osteoporosis, inflammatory disease, fracture), those who are pregnant, or individuals following surgery will be excluded. The concept is eHealth interventions that support self-management conducted in any setting and geographical location. All settings and locations will be included.

METHODS

The following electronic databases will be searched with no limit on publication date: MEDLINE, CINAHL, PsycINFO, Embase, Scopus and the Cochrane Database of Systematic Reviews. A structured search of the gray literature will also be conducted. Studies will be limited to those published in English. Two reviewers will undertake title and abstract screening, followed by full-text screening. Data extraction will be conducted utilizing a standardized form for included studies, and a narrative summary will accompany the charted results and will describe how the results relate to the review's objective.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (https://osf.io/29rd6).

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

Evaluation of an educational intervention that aims to improve the keep/refer decision-making abilities of Austrian undergraduate physiotherapy students: a randomised pilot study

Background/Aims

An ongoing discussion about direct access to physiotherapy for patients with musculoskeletal pain disorders in Austria requires the development of a curriculum that educates physiotherapy students to make autonomous decisions to treat the patient without the need for medical referral (keep), to treat the patient with additional medical check-up (keep and refer) or to send the patient for medical evaluation without physiotherapeutic management (refer), and to recognise the presence of serious pathologies. The aim of this study was to examine the feasibility, acceptability and potential effectiveness of an educational intervention that was provided to Austrian physiotherapy students in their final semester of the 3-year undergraduate (bachelor) degree.

Methods

An educational intervention was given to Austrian physiotherapy students in their final semester of the 3-year undergraduate (bachelor) degree, which consisted of a single, 1-hour face-to-face case-based lecture on the principles of differential diagnosis, screening for possible red flag pathologies and review of the body systems. A control group did not receive the intervention, but both groups completed 11 validated vignettes.

Results

Half of Austrian universities (n=6/12) and 116 final year Austrian undergraduate physiotherapy students took part in the study. All students from the intervention group were satisfied with the intervention and 77.6% found the intervention beneficial for making keep/refer decisions based on clinical vignettes. Overall, 89.7% did not find the intervention too time consuming. A potential effectiveness of the intervention could not be demonstrated.

Conclusions

Future similar studies need to investigate if more teaching hours and/or if different educational methods are capable of improving the keep/refer decision-making abilities of Austrian undergraduate physiotherapy students.

The use of posture-correcting shirts for managing musculoskeletal pain is not supported by current evidence - a scoping review of the literature

BACKGROUND AND AIMS

The concept of bad posture being a dominant driver of pain is commonly held belief in the society. This may explain the significant attention supportive clothing such as posture-correcting shirts has recently gained in Scandinavia and the USA. The aim of this scoping review was to present an overview and synthesis of the available evidence for the use of posture-correcting shirts aimed at reducing pain or postural discomfort and optimising function/posture.

METHODS

A systematic search was conducted for literature investigating the effect of posture-correcting shirts on musculoskeletal pain or function. PubMed, Embase, CINAHL, PEDro and the Cochrane Library were searched for relevant literature. Results of the searches were evaluated by two independent reviewers in three separate steps based on title, abstract and full text. For data synthesis, the population, intervention, comparator and outcome were extracted. The quality of the literature was evaluated using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and the risk of bias was assessed using the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) assessment tool or the RoB 2.0 tool for individually randomized, parallel group trials. The overall confidence in the literature was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 136 articles were identified and six of these were included in the review. These studies were heterogeneous with regards to aims, outcomes and methods, presenting contrasting results. The overall findings were that posture-correcting shirts change posture and subjectively have a positive effect on discomfort, energy levels and productivity. The quality of the included literature was poor to fair with only one study being of good quality. The risk of bias was serious or critical for the included studies. Overall, this resulted in very low confidence in available evidence. An important limitation of all studies was that they were conducted in pain-free individuals.

CONCLUSIONS

The contrasting findings and the low quality of current literature, questions the intended effect of posture-correcting shirts and whether the changes it creates are in fact useful for clinical practice. Moreover, the findings are contrasted by the available evidence regarding posture and pain with a particular focus on whether this management strategy may have a detrimental effect on people living with musculoskeletal pain. A major limitation to the existing literature on the effect of posture-correcting shirts is that no studies have investigated their effect in clinical populations.

IMPLICATIONS

Based on the available literature and the major limitation of no studies investigating clinical populations, there is no good quality evidence to support recommendation of posture-correcting shirts as a management strategy for musculoskeletal pain. Promotion of this product may reinforce the inaccurate and unhelpful message that poor posture leads to pain. The efficacy of such garments should be tested in clinical populations and not only in pain-free individuals, to assess whether there is any meaningful benefit of this management approach. Until then, the use of posture-correcting shirts for musculoskeletal pain is not supported by current evidence.

The Global Spine Care Initiative: resources to implement a spine care program

PURPOSE

The purpose of this report is to describe the development of a list of resources necessary to implement a model of care for the management of spine-related concerns anywhere in the world, but especially in underserved communities and low- and middle-income countries.

METHODS

Contents from the Global Spine Care Initiative (GSCI) Classification System and GSCI care pathway papers provided a foundation for the resources list. A seed document was developed that included resources for spine care that could be delivered in primary, secondary and tertiary settings, as well as resources needed for self-care and community-based settings for a wide variety of spine concerns (e.g., back and neck pain, deformity, spine injury, neurological conditions, pathology and spinal diseases). An iterative expert consensus process was used using electronic surveys.

RESULTS

Thirty-five experts completed the process. An iterative consensus process was used through an electronic survey. A consensus was reached after two rounds. The checklist of resources included the following categories: healthcare provider knowledge and skills, materials and equipment, human resources, facilities and infrastructure. The list identifies resources needed to implement a spine care program in any community, which are based upon spine care needs.

CONCLUSION

To our knowledge, this is the first international and interprofessional attempt to develop a list of resources needed to deliver care in an evidence-based care pathway for the management of people presenting with spine-related concerns. This resource list needs to be field tested in a variety of communities with different resource capacities to verify its utility. These slides can be retrieved under Electronic Supplementary Material.