Musculoskeletal disorders – a challenge to society and to physiotherapists

Abstract

Musculoskeletal disorders (MSDs), particularly back and neck pain, is a challenge for society due to high prevalence, high disability and high costs. It occurs in high-income, middleincome and low-income countries and in all age groups. Years lived with disability caused by low back pain (LBP) has increased by 54% between 1995 and 2015 and has now become number one cause of disability. The Lancet series about LBP in 2018 underlined that pathoanatomy often is unclear and that imaging adds little and should be used much less as most LBP-conditions are unrelated to specifically identifiable abnormalities. Furthermore, increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling LBP [1]. Globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections and surgery. Many patients get the wrong care, and a lot of money is used on wrong and/or unnecessary care. Invasive care has a limited, if any, role and use of opioids in treatment of MSDs must be avoided. Neuroscience knowledge has done advances and fortunately put the mind and body back together and a multidimensional treatment approach has become more usual. Clinical practice guidelines encourage a management approach that is both patient-centred and patient-informed, addressing psychosocial factors and focussing on increasing or maintaining activity and selfmanagement. Although guidelines recommend prudent use of medication, imaging and surgery, medication and surgery have unfortunately been on the rise in many countries and multidimensional and multidisciplinary care on the decline [2]. Physiotherapists (PTs) must acknowledge that a broader recognition of multi-morbidity is necessary for assessment and treatment of MSDs, particularly in those with persistent problems. We cannot focus on pain symptoms and function alone, but also recognise accompanying problems such as negative beliefs, pain-related fear, sleep disturbance, inactivity, anxiety and depression. Therapists must remember to ask questions about patients working life. Too many too often do not ask or get enough information about the working conditions and the patients working history. Furthermore, care must be strategic and classified. Some patients need just advice and manage better on their own; others need assistance from PTs to change their illness perception and beliefs about pain in order to self-manage their problems. Only by doing this, we can tailor care better and increase patient-centred and supported self-care management. Studies have shown much better results when having a biopsychosocial approach compared to a symptom focussed and biomedical approach, and improvement in function can be maintained over time when a healthier life-style has been adopted [3,4]. Clinical practice, research and policy-making are often representing different worlds, but are dependent upon each other. Treatment must be payable, accessible, effective and evidence-based. Guidelines and standards are central, and policymakers look at effectiveness, cost-effectiveness, necessity (burden of disease), feasibility and should take out care that does not work, as well as its’ funding. For example, in the Nederland radiofrequency denervation of facet/IS-joints and discs has not being reimbursed after 2016 due to lack of demonstrating effect, as physiotherapy alone showed the same effect. However, this is still a treatment offered in many countries. Professionals that have criticised and tried to change guidelines that have opened for less injections and fusion surgery have, however, been personally attacked by strong interest groups representing this type of treatments. The drug industry have enormous budgets and aggressive marketing strategy tactics for promoting drugs, and opioids are presently causing an increasing number of deaths (more than in vehicle accidents in USA), and with high rates of dependency and addiction [2,5]. So how can we meet the challenges and improve care in MSDs? More countries should follow the policy in Nederland where the government requires high-quality RCTs in order to provide funding/coverage for new expensive treatments. Stakeholders must join forces in building evidence. We can change beliefs and culture, both in health personnel and in patients. Public health campaigns have developed messages about the importance of staying active, cognitive reassurance, the nature of LBP not meaning damage and that the prognosis is good. We can change our treatment approach, update our education and we can aim to change compensation systems. Communicate with patients. Change public perceptions through use of media, including Facebook. Be certain of facts and strive for impeccable science, and use own experience and real stories as good examples. Decision aids can be both booklets and videos. Videos have been shown to better inform and aid patients in their shared-decision making than just by conversation and booklets. A major challenge will be to stop use of harmful practices while ensuring access to effective and affordable health care for people with LBP [5]. PTs’ who have changed to behaviour and cognition treatments improves care.