A new paradigm for musculoskeletal pain care: moving beyond structural impairments. Conclusion of a chiropractic and manual therapies thematic series

Abstract

This commentary closes the thematic series “A new paradigm for musculoskeletal pain care: moving beyond structural impairments”. The papers published in the series point to key aspects of shifting the paradigm of musculoskeletal care from clinician-led management often focused on addressing presumed structural anomalies to partnering with patients to find individual strategies that empower patients towards self-management. Several papers in the series highlighted the need for developing patient-centred models of care that respect individual patient’s needs and preferences. Also, the series pointed to different options for modes of delivery including mHealth and the challenges and opportunities they present for developing person-centred strategies. For health care to provide effective support for people with musculoskeletal pain conditions, there is a need to recognise that contextual factors, including a strong patient-provider alliance, clearly play an important, perhaps primary, role. Health care professions dealing with musculoskeletal pain conditions should engage in research to investigate effective ways to move this understanding into practice including how to train providers. We hope the work collected in this series will stimulate further questions and more research as musculoskeletal pain providers seek to make their care more person-centred.

Background

It has long been recognised that musculoskeletal pain conditions are a result of a complex interaction of biological, psychological, and social factors that cannot be resolved by addressing structural injury or impairment alone. Rather, clinical guideline advocate a person-centred approach that supports patient self-management. Person-centred care necessitates consideration of the context within which care is provided, how patients interact with providers, and the cognitive and emotional responses of both patients and clinicians. These considerations have previously been dismissed as “non-specific” or part of a placebo effect, but increasing recognition of the clinical relevance of these contextual factors requires a re-conceptualization of their role [1]. Considering these factors is not in contrast to providing evidence-based treatments such as exercise therapy and manual therapies, but offers an opportunity to consider how clinician-led, evidence-based interventions may be integrated while supporting and encouraging patient self-management through person-centred care.

In July 2021, Chiropractic and Manual Therapy called for submissions to a thematic series under the heading “A new paradigm for musculoskeletal pain care: moving beyond structural impairments”. The intension was to contribute to discussions and reflections on ways that health care providers and systems that have traditionally focused on structural diagnosis and impairment can take a role in improving person-centred musculoskeletal pain care and facilitating self-management. With eight papers published in the series we will now discuss what we have learned from these contributions.

Which topics were addressed?

The papers included in this thematic series use of variety of methodologies to examine important aspects of person-centred care that move beyond the paradigm of structural impairments (Table 1). Collectively the papers in this series identify and explore contextual factors that can impact outcomes irrespective of the specific structural interventions used including patients’ and providers’ beliefs, expectations and characteristics, the patient-provider working relationship, and characteristics of the therapeutic environment such as the mode of delivery (telehealth, mHealth, etc.). The topics addressed provide a reminder that contextual factors are not indescribable placebo effects but relate to all aspects of care than goes beyond addressing a specific structural mechanism.

Table 1 Summary of the paper included in the thematic series

Two papers in the series used qualitative methods to explore patients’ experience with interventions focused on promoting self-management of chronic back pain through a group-based education and exercise program [2] or an app-based education, exercise and physical activity interventions [3]. Belton and colleagues provide additional insights on the patient’s perspective of care by exploring the narrative of one patient and her experience with seeking care for persistent pain [4]. The critical nature of the patient-provider relationship, or working alliance, is further explored in the mixed methods systematic review by Ivanova and colleagues [5]. Advances in technology and changes in response to the COVID pandemic are accelerating the use of telehealth, which raises unique challenges for developing an effective patient-provider relationships. This and other important considerations for using telehealth delivery are explored in the commentary by Saragiotti and colleagues [6].

Issues addressed in this thematic series have important implications for clinical practice, as well as clinical research and the education of health care practitioners providing care for persons with musculoskeletal pain conditions. The systematic reviews by Ivanova and colleagues and Sherriff et al. [7] identify gaps in our knowledge on the impact of specific contextual factors such as working alliance, and expectations and beliefs about pain on outcomes. In addition, the review by Sherriff and colleagues highlights the need for rigorous studies examining the effectiveness of interventions attempting to modify contextual factors during conservative care. The randomized clinical trial from Bronfort et al. [8] included in this series provides one example comparing different models for delivering conservative care (unimodal versus integrated care) and including outcomes such as pain coping strategies and self-efficacy to examine outcomes related to the development of self-management skills in the participants. Finally, Innes and colleagues [9] examine the attitudes and beliefs of students in chiropractic education programs around the perceived mechanisms of structural interventions and professional identity.

The main messages conveyed

The papers in this thematic series highlight several important issues for musculoskeletal pain care. First, contextual factors clearly play an important, perhaps primary, role in conservative care. Recognition of this reality is consistent with the biopsychosocial model and should promote further professional dialogue on how to provide care in a manner that optimizes patient-centred outcomes. The importance of contextual factors and the need to promote self-management do not obviate the role of interventions such as exercise or manual therapies. But our growing understanding of contextual factors should prompt us to consider how our traditional interventions may actually benefit patients. Beyond the structural, physiologic effects that exercise and manual therapies may have, we should consider their role in promoting patients’ self-efficacy, positive expectancies and stronger therapeutic bonds with providers. From this perspective the manner in which traditional interventions are provided may be more important than their underlying mechanical or physiologic rationale. For example, the way providers communicate with patients, set expectations and provide feedback may build the working alliance with patients and enhance their self-efficacy for self-management irrespective of the specific interventions used.

The papers in this series also make it clear that greater consideration of contextual factors that are common across interventions will make musculoskeletal pain care more personalized, not less. Accounting for patients’ needs for empathic, bi-directional communication and understanding of their individual pain experience creates the opportunity for providers to truly collaborate and keep their patients at the centre of their care and life. New delivery modes such as telehealth and mHealth strategies provide opportunities for innovative care models, but also raise unique challenges for developing working alliances and promoting person-centred care. The clinical skills necessary to form effective collaborative relationships with patients are not established, but it is clear that developing core competencies that optimize person-centred care will require different training strategies for clinicians and students at educational institutions.

Finally, the papers in this thematic series point to areas that researchers, clinicians, patients, and decision makers must collaborate around to improve the care provided to persons with musculoskeletal pain complaints. Emerging information calls attention to the critical nature of the patient-provider working alliance, yet there is presently little evidence on how to build and sustain alliances. Future research in this area must incorporate the perspectives of both patients and providers. The need for providers to facilitate and promote effective coping strategies and self-management skills for their patients is recognized, but optimal strategies for achieving these clinical objectives have not been identified. The challenge in shifting providers’ approach to patients from a perspective of fixing structural/mechanical anomalies to developing effective partnerships that help people engage in valued activities should not be under-estimated as it involves different skills as well as a shift in professional identity [10].

Also, the shift towards a more person-centred, comprehensive approach to musculoskeletal pain care offers opportunities for providers who are able to provide this care to play pivotal front-line roles. Ideally, care pathways would situate providers prepared to manage the complex biopsychosocial factors contributing to persistent musculoskeletal pain at the entry-point into health care systems as a strategy to promote self-management and reduce the risk for unwarranted escalation in care [11]. Implementing these care pathways will require collaboration with decision-makers and continuing professional development for providers. Along with evidence pointing to shared effect mechanisms across treatments for musculoskeletal pain conditions, [12, 13] the papers in this series thus point to the need to develop and test interventions to train clinicians to deliver person-centred care and ways to implement a shift in care pathways.

The editors’ conclusions

The impact of chronic, persistent musculoskeletal pain on individuals and society, and the reality that interactions with health care systems too often exacerbate instead of alleviate concerns make it clear that a transformation away from clinician-led management towards management where persons with musculoskeletal pain play a key role in their own care is necssary [14]. The papers in this thematic series highlight key considerations to inform this necessary paradigm shift. The papers also point to several gaps in the evidence to inform the development of effective and sustainable health care for musculoskeletal pain. We hope the work collected in this series will stimulate further questions and more research as musculoskeletal pain providers seek to make their care more person-centred and educational institutions develop ways to facilitate person-centred care.