Evidence-based Service design

Why do you need The RePAIR Clinic - what is currently wrong in musculoskeletal care?

Key points

Imaging at an inappropriate time, with inappropriate interpretation

Overuse of imaging: between 25% and 42% of patients with musculoskeletal (MSK) pain undergo imaging(1,2) even though its routine use is discouraged and associated with harm. Sixty-nine percent of general practitioners would refer patients for radiography at first presentation of rotator cuff tendinopathy and 82% would refer for ultrasound(3) despite findings demonstrating a poor relationship of imaging findings with symptoms.(4)

Overuse of surgery

Knee arthroscopy for knee osteoarthritis is not recommended, yet its rate of use in the general population increased from 3% to 4% from 2006 to 2010.(5) The rates of shoulder subacromial decompression and rotator cuff repair(6) have increased markedly even though surgical outcomes are comparable with exercise-based rehabilitation(7) or sham surgery.(6)

Overuse of opioid painkillers

The efficacy of opioids for MSK pain management is questionable for both chronic(8) and acute MSK pain conditions.(9) The early use of opioids has been associated with poorer outcomes in LBP care.(10) Although limiting the use of opioids is recommended,(11) there is increasing use and an ‘epidemic’ of prescription opioid-related harms.(12)

Failure to provide education and advice

These are cornerstones of managing MSK pain conditions, yet only 20% of patients were given advice and education in a primary care setting.(13)

Consistent evidence-based recommendations

• We must offer robust diagnosis, explanation and education with self-management programmes.

• Provide allied interventions targeting weight loss to people with osteoarthritis who are overweight or obese.

• Glucosamine or chondroitin are not routinely helpful for disease modification.

• There is no role for knee arthroscopy, lavage and debridement unless there is a rationale (such as mechanical knee locking) in knee osteoarthritis.

• Established therapies such as opioids, SSRIs, gabapentinoids, spinal injections (eg facet joint injections, branch blocks, intradiscal injections, prolotherapy, trigger point injections) are not helpful for chronic MSK pain.

• Instead, we must focus on maintenance of function, providing the least interventional therapies progressively, weighing potential benefit with known low safety profiles for each(14).

References

1. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the

appropriateness of health care delivery in Australia. Med J Aust 2012;197:100–5.

2. Ivanova JI, Birnbaum HG, Schiller M, et al. Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline- concordant care. Spine J 2011;11:622–32

3. Buchbinder R, Staples MP, Shanahan EM, et al. General practitioner management of shoulder pain in comparison with rheumatologist expectation of care and best

evidence: an Australian national survey. PLoS One 2013;8:e61243.

4. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol 2011;197:W713–19.

5. Adelani MA, Harris AH, Bowe TR, et al. Arthroscopy for knee osteoarthritis has not decreased after a clinical trial. Clin Orthop Relat Res 2016;474:489

6. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo- controlled, three-group, randomised surgical trial. The Lancet 2017

7. Ketola S, Lehtinen JT, Arnala I. Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomised controlled trial at a minimum follow-up of ten years. Bone Joint J 2017;99- B:799–805

8. Abdel Shaheed C, Maher CG, Williams KA, et al. Efficacy, tolerability, and dose- dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016;176:958

9. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/ acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015;314:1572–80

10. Webster BS, Verma SK, Gatchel RJ. Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use. Spine 2007;32:2127–32

11. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain–United States, 2016. JAMA 2016;315:1624–45

12. Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain 2013;154:S94–100

13. Williams CM, Maher CG, Hancock MJ, et al. Low back pain and best practice care: a

survey of general practice physicians. Arch Intern Med 2010;170:271–7

14. Lin, I., recommendationsWiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C.G. and O’Sullivan, P.P., 2020. What does best practice care for musculoskeletal pain look like? Eleven consistent from high-quality clinical practice guidelines: systematic review. British journal of sports medicine, 54(2), pp.79-86.