An Overview of MSK Management by Most Common Conditions

Global Pathologies

Osteoarthritis

Education regarding weight reduction and exercise;

The provision of appropriate simple orthoses, aids and appliances to alleviate distress and disability

Rheumatoid Arthritis Screen for those at greatest risk of loss of function, self-efficacy, physical and psychological status and pain;

A co-ordinated management programme, including patient education, joint protection training, exercise therapy, and appropriate provision of orthoses, mobility aids and environmental adaptations

Intensive co-ordinated in or day patient rehabilitation for people with active or severe RA

Other secondary health problems associated with poor mobility, such as thrombo-embolic disease and pressure sores, need to be considered and appropriate preventative strategies introduced

Fibromyalgia and CRPS In both fibromyalgia and CRPS, the severity of the disabling pain needs to be acknowledged

In CRPS, strategies to alleviate pain are seldom effective long-term, but the use of local treatments eg regional nerve blocks, protective and/or off-loading orthoses, may facilitate commencing rehabilitation.

Cognitive behavioural therapy (CBT) combined with rehabilitation to promote independence and return to normal lifestyle are the mainstays of treatment.

For fibromyalgia, initial management should include patient education supplemented by physiotherapy, particularly graded aerobic exercise programmes, but CBT again plays a crucial role

These are conditions where success is probably more dependent on the interest and commitment of treating clinicians than their professional background and speciality.

Osteoporosis

Ensure high risk groups presenting with fractures are appropriately screened and osteoporosis treatment initiated when indicated.

Adequate bone densitometry should be provided to ensure the screening of all high-risk groups.

Other secondary health problems associated with poor mobility such as thrombo-embolic disease and pressure sores need to be considered and appropriate preventative strategies introduced.

Local Conditions

Joint replacement surgery

Include a pre-operative assessment, and adequate provision of peri-operative and post-operative therapy. With current trends in sub-specialisation, orthopaedic correction for inflammatory polyarthritis can involve four or five different surgeons.

Hence, there is a role for a physician, either rehabilitationist or rheumatologist, to co-ordinate overall management.

Soft tissue problems

Patients with ‘red flags’ denoting risk of serious underlying pathology should be given prompt access to appropriate investigations

After initial triage to identify those who may require immobilisation or surgical repair, PRICE (protection, rest, ice, compression, and elevation) should be used for the first 72 hours to alleviate early inflammation.

This needs to be followed by a carefully co-ordinated programme of rehabilitation, which encourages mobilisation and addresses risk factors (eg vulnerability to falls in the elderly), thus reducing the likelihood of chronicity.

As well as providing symptom relief, physiotherapy (and in some cases orthoses to stabilise unstable joints), the role of rehabilitation is to identify trigger situations and develop strategies to alter/reduce mechanical demands. This will usually involve task observation. Psychological actors and concerns, which might impede recovery eg impact on income, will also need to be considered.

Spinal pain

Those with acute spinal pain need adequate pain relief and advice to keep as active as possible.

For those with subacute or chronic pain, rehabilitation should include postural re-education, a

graded exercise programme, and access to psychological interventions including cognitive

behavioural therapy and vocational rehabilitation.

Ankle and Neck

Commonest sites of soft tissue injury are the ankle (5,000 per day in UK), and neck (nearly 700

per day). Whilst spontaneous recovery is to be expected in the majority of cases, a minority will

have persistent or recurrent problems leading to pain and disability often affecting work and

lifestyle.

Shoulder problems

Patients with complete rotator cuff tears or other significant underlying (rheumatological or

neurological) problems need referral for investigation and/or surgery. There is little evidence to

guide choice of treatment for the remainder. Some 40-50% have persistent pain and disability. In

particular, aspects of personal care may be hampered. These aspects require early recognition and

intervention, if necessary with aids as well as home and/or workplace adaptations.