By Anna-Marie Schmidt, MM, DC, and Robert Vining, DC, DHSc
Research evidence suggests following guideline recommendations can improve quality of care and clinical outcomes.1–3 However, translating recommendations into clinical care for individuals can be challenging because guidelines, by nature, tend to inform care on a general level.
Further complicating guideline adherence is confusion caused by inconsistent terminology, the existence of multiple guidelines for single conditions, poor transparency in describing how evidence is interpreted, and a failure to describe or recommend implementation strategies.4,5 Inconsistent recommendations within guidelines raises the question, “Is there common ground among guidelines for musculoskeletal conditions?” To answer this question, researchers identified 11 recommendations that consistently appear within current guidelines (Table 1).4 In this article, we address three commonly occurring recommendations.
Table 1: Best practice recommendations for musculoskeletal care4
||Care that accounts for individual preferences and incorporates shared decision making|
||Identify possible serious pathology|
||Includes emotions, fears, social support, and recovery expectations|
||Consider when serious pathology is suspected, or there has been limited response to care|
||Assess mobility, strength, position and proprioception, and neurological function when applicable|
||Evaluate using validated outcome measures|
||Inform about condition and management options|
||Recommend normal physical activity or other exercise when applicable|
||Use manual therapy with other treatments in the context of multimodal care|
||Offer conservative care prior to considering surgery|
||Encourage continuation and/or early return to work|
Recommendation No. 5: Undertake a physical examination
Assessing and diagnosing some musculoskeletal problems can be challenging. Musculoskeletal problems can involve multiple overlapping conditions with similar symptoms, making a diagnosis sometimes difficult to confirm.6,7 The inherent difficulties of assessing musculoskeletal conditions can be further complicated by lack of confidence in conducting certain tests, developing specific working diagnoses, or perceiving some tests take too much time.8 The recommendation suggests consistently assessing key factors, which include mobility/movement, strength, position and proprioception, and neurological function when clinically indicated.4
Recommendation No. 9: Use manual therapy only as an adjunct to other treatments
Using a manual therapy as a sole intervention generally places patients in the role of passive recipient. Passive-only approaches tend to:9,10
- promote pain relief as the major goal of care, rather than functional improvement
- teach dependence on clinicians rather than promoting self-efficacy and self-management
- inadvertently promote physical deconditioning
This recommendation does not suggest chiropractic care should be relegated to adjunct status or that passive therapies are inherently inappropriate. Instead, it suggests manual therapies should be applied with other interventions in a multimodal approach whenever possible. Exercise and self-management advice are evidence-based co-interventions commonly utilized by chiropractors11 and recommended treatment strategies for spinal and other musculoskeletal conditions.12–16
Recommendation No. 7: Provide education/information
Education is a clinical intervention that supports and enables people to manage their condition(s), and optimize health and well-being.17 With differing needs, individuals require tailored education to understand a diagnosis, treatment options, prognosis, and self-management strategies. Evidence now strongly supports the best practice of making education a part of all clinical encounters.4
Potential benefits of education can include:18,19
- reduced pain-related distress through reassurance about a condition
- enabling people to take a more active role in their own health by gaining greater knowledge and awareness of their condition(s)
- increased confidence in personal ability to cope by fostering engagement in peer-support activities
Characteristics of evidence-based health education include:20
- Learning process: Facilitates knowledge building to promote voluntary decisions about health-related behaviors
- Health-focused: Communicates the concept of health as occurring along a dynamic fluctuating timeline
- Multidimensional: Considers intrapersonal (cognitive abilities, emotions, resilience) and external (social environment, resources) factors impacting a person’s health
- Person-centered: Adapts to each person’s health needs, meets them at their level, and considers individual experiences and abilities
- Partnership: Is a collaboration between doctor and patient, based on respect and freedom of choice
One way to help systematically implement recommendations in practice is to convert them into a paper, electronic, or mental checklist, as displayed in Figure 1. Alternatively, shorter checklists comprised of Yes/No questions designed for initial, follow-up, or re-evaluation visits can be used. Potential benefits can include promoting a strong doctor-patient relationship, preventing unintended and unfavorable consequences, and supporting or improving clinical outcomes.
Figure 1. Best practices for musculoskeletal care checklist
- Were patient preferences considered?
- Was serious pathology screened?
- Were psychological and social factors assessed?
- Is imaging needed to assess for pathology or poor response?
- Was mobility, strength, and neurological function assessed?
- Was patient progress monitored?
- Was condition and/or management education included?
- Was exercise recommended?
- Was a multimodal approach used?
- Is conservative care appropriate?
- Was continuing, or returning, to work encouraged?
Anna-Marie Schmidt, MM, DC, is a Post-Doctoral Research Scholar at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.
Robert Vining, DC, DHSc, is Associate Dean of Clinical Research at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic.
- Mesner SA, Foster NE, French SD. Implementation interventions to improve the management of non-specific low back pain: a systematic review. BMC Musculoskelet Disord. 2016;17(258).
- Lugtenberg M, Burgers JS, Westert GP. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual Saf Health Care. 2009;18(5):385-392.
- Bishop P, Quon J, Fisher C, Dvorak M. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain – ScienceDirect. Spine J. 2010;10:1055-1064.
- 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. March 2019:bjsports-2018-099878. doi:10.1136/bjsports-2018-099878
- Lin I, Wiles LK, Waller R, et al. Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. Br J Sports Med. 2018;52(5):337-343. doi:10.1136/bjsports-2017-098375
- Negrini S, Zaina F. The Chimera of Low Back Pain Etiology: A Clinical Rehabilitation Perspective. American Journal of Physical Medicine & Rehabilitation. 2013;92(1):93-97. doi:10.1097/PHM.0b013e31827df8f5
- Deyo RA, Dworkin SF, Amtmann D, et al. Report of the National Institutes of Health Task Force on Research Standards for Chronic Low Back Pain. Journal of Manipulative and Physiological Therapeutics. 2014;37(7):449-467. doi:10.1016/j.jmpt.2014.07.006
- Hall AM, Scurrey SR, Pike AE, et al. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implement Sci. 2019;14. doi:10.1186/s13012-019-0884-4
- Cosio D, Lin E. Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Glob Adv Health Med. 2018;7. doi:10.1177/2164956118768492
- Du S, Hu L, Dong J, et al. Self-management program for chronic low back pain: A systematic review and meta-analysis. Patient Education and Counseling. 2017;100(1):37-49. doi:10.1016/j.pec.2016.07.029
- National Board of Chiropractic Examiners. Chapter 9: Professional Functions and Treatment Procedures. In: Christensen M, Hyland J, Goertz C, et al., eds. Practice Analysis of Chiropractic 2018.
- Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain. 2017;21(2):201-216. doi:10.1002/ejp.931
- Bussières AE, Stewart G, Al-Zoubi F, et al. Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative. Journal of Manipulative and Physiological Therapeutics. 2018;41(4):265-293. doi:10.1016/j.jmpt.2017.12.004
- Parikh P, Santaguida P, Macdermid J, Gross A, Eshtiaghi A. Comparison of CPG’s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review. BMC Musculoskelet Disord. 2019;20. doi:10.1186/s12891-019-2441-3
- Sutton DA, Côté P, Wong JJ, et al. Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. The Spine Journal. 2016;16(12):1541-1565. doi:10.1016/j.spinee.2014.06.019
- National Institute for Health and Clinical Excellence (NICE). Osteoarthritis: Care and Management (CG177). London: National Institute for Health and Clinical Excellence; 2014.
- Stenberg U, Vågan A, Flink M, et al. Health economic evaluations of patient education interventions a scoping review of the literature. Patient Education and Counseling. 2018;101(6):1006-1035. doi:10.1016/j.pec.2018.01.006
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