Is the "Standard" of Musculoskeletal Pain Care Good for Patient?

 Interventions such as prescription of nonsteroidal antiinflammatory drugs and intraarticular injection of corticosteroids have been investigated repeatedly, in well designed, randomized, controlled trials, and the results do riot support their use (3,4,7), 

The efficacy of epidural steroid injections for low back pain was assessed as well. The best studies showed inconsistent results of epidural steroid injections. The efficacy of epidural steroid injections has not been established. The benefits of epidural steroid injections, if any, seems to be of short duration only (8). 

Meta analyses were performed for spinal manipulation, exercise therapy, traction, ultrasound, and laser therapy, and for disorders of the back neck, shoulder and knee. In general, the methodological quality of the studies appeared to be low, and the efficacy of physiotherapy was shown to be convincing for only a few indications and treatments (1,2,9) 

Disparities between current practice and the knowledge base are epitomized by the results of a recent study. Baruji et al' reported that three consultant rheumatologists who each examined a cohort of patients with shoulder pain diagnosed a variety of conditions, about which they agreed in only 46% of cases, yet all recommended the same treatment, injection of corticosteroid, in almost every case (6). 

It seem that senior clinicians recognized as experts in the field are unable to determine what is wrong with painful shoulders, yet they unswervingly apply treatment that has been shown to be ineffective. 

When the evidence base challenges traditional practices, clinicians tend to respond in one of three ways. Some choose to ignore the evidence and simply go on as before; effectively they abandon the scientific method as the basis of medicine. Some acknowledge the evidence but rationalize that it does not apply to them, that somehow their practices are not subject to the liabilities shown in the literature; this also amounts to denial of the scientific method . The third scientific response is to accept the bad news, to assess its significance and then to reevaluate and modify methods of practice accordingly, even if that means giving up traditional interventions and seeking more effective ways of managing patients' problems. The evidence on the current management of musculoskeletal pain presents several such challenges. 

References

1.       Feine, JS, Lund PL. An assessment of the efficacy of physical therapy and physical modalities for the control of chronic musculoskeletal pain. Pain, 1997; 71: 5-23.

2.       van der HeJjden GJMG, van der Windt DAWK de Winter AF. Physiotherapy for patients with soft tissue shoulder disorders. Br Med J, 1997; 315: 25-29.

3,       van der Windt DAWK van der HeiJden GJMG, Scholten RJPNL Koes BW, Bouter LM. The efficacy of non-steroidal           anti-inflammatory drugs (NSAIDS) for shoulder complaints, A systematic review. J. Clin Epidemiol, 1995; 48: 691­704.

4.       van der HeiJden GJMG, van der Windt DAWM, Ydeijaen J, Koes BW, Bouter LM. Steroid injections for shoulder disorders. a systematic review of randomized clinical trials. Br J Gen Pract, 1996 46: 301) 316.

5.       Green, S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomized controlled trials of interventions for painful shoulder, selection criteria, outcome assessment and efficacy. BMT, 1998; 316: 354-360.

6.       Bamii AN, Erhardt CC, Price TR, Williams PL. 1he painful shoulder: can consultants agree? Br J Rheumatol, 11996; 35: 1172-1174.

7.       Koes BW, Scholten RJ, Mens JM, Bouter LM: Efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomized clinical trials. Ann Rheum Dis 1997 Apr;56(4):214-223

8.       Koes BW, Scholten RJ, Mens JM, Bouter LM: Efficacy of epidural steroid injections for low back pain and sciatica: a systematic review of randomized clinical trials. Pain 1995 Dec;63(3):279-288

9.       Beckerman R Bouter LK van der 1*Jjden GJ, de Bie RA, Koes BW: Efficacy of physiotherapy for musculoskeletal disorders: what can we learn from research? Br J Gen Pract 1993 Feb;43(367):73-77